FOOD AND DRUG ADMINISTRATION








                              MEETING #37






                        Thursday, March 18, 2004


                               8:30 a.m.



                              Hilton Hotel

                        Silver Spring, Maryland






      Mahendra S. Rao, M.D., Ph.D., Chair

      Gail Dapolito, Executive Secretary



      Jonathan S. Allan, D.V.M.

      Bruce R. Blazar, M.D.

      David M. Harlan, M.D.

      Katherine A. High, M.D.

      Joanne Kurtzberg, M.D.

      Alison F. Lawton

      James J. Mul, Ph.D.

      Thomas H. Murray, Ph.D.

      Anastasios A. Tsiatis, Ph.D




      Jeffrey S. Borer, M.D.

      Susanna Cunningham, Ph.D.

      Jeremy N. Ruskin, M.D.

      Michael E. Schneider, M.D.

      Michael Simons, M.D.




      John F. Neylan, M.D.




      Norman Viner, M.D.




      Stephen Epstein, M.D.

      Silviu Itescu, M.D.

      Robert J. Lederman, M.D.

      Philippe Menasch, M.D.

      Emerson C. Perin, M.D., F.A.C.C.

      Doris A. Taylor, Ph.D.




      Richard O. Cannon, M.D.

      Stephen M. Rose, Ph.D.




      Jesse L. Goodman, M.D., M.P.H.

      Philip Noguchi, M.D.

      Dwaine Rieves, M.D

      Stephen Grant, M.D.

      Richard McFarland, Ph.D., M.D.

      Donald Nick Jensen, D.V.M., M.S.E.E.




                            C O N T E N T S



      Call to Order

        Mahendra Rao, M.D., Ph.D., Chair                         5


      Conflict of Interest Statement

        Gail Dapolito, Executive Secretary                       5


      Introduction of Committee                                  9


      FDA Opening Remarks

         Presentation of Certificate of Appreciation

         to Retiring Member

         Jesse Goodman, M.D., M.P.H.                            14

         Philip Noguchi, M.D.                                   16


                        Open Committee Discussion

                 Cellular Therapies for Cardiac Disease


      FDA Introduction and Perspectives

        Dwaine Rieves, M.D.                                     18


      Guest Presentations


        Overview Cardiomyopathy and Ischemic Heart


        Emerson Perin, M.D., Ph.D.                              35

        Q&A                                                     65


        Clinical Experience of Autologous Myoblast


        Philippe Menasch, M.D.                                 85

        Q&A                                                    115


        Bone Marrow Cell Therapy for Angiogenesis:

        Present and Future

        Steven Epstein, M.D.                                   128

        Q&A                                                    148


      Cellular Therapies for Cardiac Disease

      Richard McFarland, Ph.D., M.D.                           159


      Guest Presentations


        Myoblasts:  The First Generation Cells for

        Cardiac Repair: What Have We Learned?

        Doris Taylor, Ph.D.                                    169

        Q&A                                                    202


        Preclinical Models  - Hematopoietic and

        Mesenchymal Cell Therapies for Cardiac Diseases

        Silviu Itescu, M.D.                                    219

        Q&A                                                    245




                      C O N T E N T S (Continued)


        From Mouse to Man:  Is it a Logical Step for

        Cardiac Repair?

        Doris Taylor, Ph.D.                                    257

        Q&A                                                    275


        Cardiac Catheters for Delivery of Cell Suspension

        Donald Nick Jensen, D.V.M., M.S.E.E.                   292


        Transcatheter Myocardial Cell Delivery: Questions

        and Considerations from the Trenches

        Robert Lederman, M.D.                                  307

        Q&A                                                    333


      Open Public Hearing                                      343




  1                      P R O C E E D I N G S


  2                          Call to Order


  3             DR. RAO:  Good morning.  Welcome to the


  4   37th meeting of the Biological Response Modifiers


  5   Advisory Committee.


  6             Today's topic, as you all know, is related


  7   to use of cells in cardiovascular disorders, and we


  8   have a pretty full schedule for the next couple of


  9   days, but before we can start the meeting, we have


 10   to have a few sort of committee stuff that needs to


 11   be gotten through, so I will turn the mike over to


 12   Gail, so that she can make the mandatory


 13   announcements.


 14                  Conflict of Interest Statement


 15             MS. DAPOLITO:  Good morning.


 16             The following announcement addresses


 17   conflict of interest issues associated with this


 18   meeting of the Biological Response Modifiers


 19   Advisory Committee on March 18 and 19, 2004.


 20             Pursuant to the authority granted under


 21   the Committee Charter, the Associate Commissioner


 22   for External Relations, FDA, appointed Drs. Jeffrey


 23   Borer and Susanna Cunningham as temporary voting


 24   members.


 25             In addition, the Director of FDA's Center




  1   for Biologics Evaluation and Research, appointed


  2   Drs. Jeremy Ruskin, Michael Schneider, and Michael


  3   Simons as temporary voting members.


  4             Based on the agenda, it was determined


  5   that there are no specific products considered for


  6   approval at this meeting.  The committee


  7   participants were screened for their financial


  8   interests.  To determine if any conflicts of


  9   interest existed, the agency reviewed the agenda


 10   and all relevant financial interests reported by


 11   the meeting participants.


 12             The Food and Drug Administration prepared


 13   general matters waivers for participants who


 14   required a waiver under 18 U.S.C. 208.  Because


 15   general topics impact on many entities, it is not


 16   prudent to recite all potential conflicts of


 17   interest as they apply to each member.


 18             FDA acknowledges that there may be


 19   potential conflicts of interest, but because of the


 20   general nature of the discussions before the


 21   committee, these potential conflicts are mitigated.


 22             We note for the record that Dr. John


 23   Neylan is participating in this meeting as a


 24   non-voting industry representative acting on behalf


 25   of regulated industry.  Dr. Neylan's appointment is




  1   not subject to 18 U.S.C. 208.  He is employed by


  2   Wyeth Research and thus has a financial interest in


  3   his employer.


  4             With regards to FDA's invited guest


  5   speakers and guests, the agency determined that


  6   their services are essential.  The following


  7   disclosures will assist the public in objectively


  8   evaluating presentations and/or comments made by


  9   the participants.


 10             Dr. Stephen Epstein is the Executive


 11   Director, Cardiovascular Research Institute,


 12   Washington Hospital Center.  He receives research


 13   support, is a consultant to and has financial


 14   interests with, firms that could be affected by the


 15   committee discussions.


 16             Dr. Philippe Menasch is employed at the


 17   George Pompidou Hospital in Paris, France.  He has


 18   an association with a firm that could be affected


 19   by the committee discussions.


 20             Dr. Emerson Perin is employed by the Texas


 21   Heart Institute.  He receives consultant fees from,


 22   and is a scientific advisor to, firms that could be


 23   affected by the committee discussions.


 24             Dr. Doris Taylor is employed by the


 25   University of Minnesota, Center for Cardiovascular




  1   Repair.  She receives consultant fees from a firm


  2   that could be affected by the committee


  3   discussions.


  4             Dr. Norman Viner is employed by the


  5   Biologics and Radiopharmaceuticals Evaluation


  6   Centre, Biologics and Genetic Therapies


  7   Directorate, Health Canada, in Ottawa, Canada.


  8             FDA participants are aware of the need to


  9   exclude themselves from the discussions involving


 10   specific products or firms for which they have not


 11   been screened for conflicts of interest.  Their


 12   exclusion will be noted for the public record.


 13             With respect to all other meeting


 14   participants, we ask in the interest of fairness


 15   that you state your name, affiliation, and address


 16   any current or financial involvement with any firm


 17   whose product you wish to comment upon.


 18             Waivers are available by written request


 19   under the Freedom of Information Act.


 20             Thank you, Dr. Rao.


 21             DR. RAO:  Now you know why I always have


 22   Gail read that statement.


 23             Before we start any committee work, I


 24   would like to welcome two new members to the


 25   committee, Dr. Murray and Dr. James Mul.  We




  1   generally introduce everyone on the committee


  2   first, and we generally go in alphabetical order,


  3   but this time I will try and start with the new


  4   members, so that they can tell us a little bit


  5   about themselves before we have the others


  6   introduce themselves.


  7                    Introduction of Committee


  8             DR. MULE:  I am Dr. Jim Mul.  I am


  9   currently the Associate Center Director for the H.


 10   Lee Moffitt Cancer Center in Tampa.  I oversee all


 11   translational research at the Center including all


 12   cell-based therapies for the treatment of cancer as


 13   it applies to the clinical treatment of patients


 14   with advance tumors.


 15             Prior to being in Tampa since September of


 16   last year, I was at the University of Michigan


 17   Cancer Center for 10 years, and prior to that, the


 18   NCI for another 10 years, and I am delighted to be


 19   here.


 20             DR. MURRAY:  Good morning.  I am Tom


 21   Murray.  I am President of the Hastings Center,


 22   which is celebrating its 35th years as the world's


 23   first research institute devoted to ethics in


 24   medicine and the life sciences.


 25             I spent 15 years as professor at medical




  1   schools including 12 at Case Western Reserve


  2   University School of Medicine.  My interests are


  3   fairly broad.  I write a lot about ethics and


  4   ethics in the life science and science policy.


  5             Thank you.  I am delighted also to be


  6   here.


  7             DR. RAO:  If we can go down the table, Dr.


  8   Tsiatis.


  9             DR. TSIATIS:  Hi.  I am Butch Tsiatis.  I


 10   am from the Department of Statistics at North


 11   Carolina State University.


 12             DR. BORER:  My name is Jeff Borer.  I am a


 13   cardiologist.  I work at Weill Medical College of


 14   Cornell University in New York City.  I run a


 15   division and an institute at Cornell and, relevant


 16   to this meeting, I am the Chairman of the


 17   Cardiorenal Drugs Advisory Committee of the FDA.


 18             DR. CUNNINGHAM:  Good morning.  My name is


 19   Susanna Cunningham.  I am a professor in the School


 20   of Nursing at the University of Washington in


 21   Seattle, and I am the consumer representative for


 22   the Cardiovascular Renal Advisory Committee.


 23             DR. SCHNEIDER:  I am Michael Schneider.  I


 24   co-direct the Center for Cardiovascular Development


 25   at Baylor College of Medicine, and our interests




  1   are in the molecular genetics of cardiac muscle


  2   formation, cardiac growth, cardiac cell apoptosis


  3   and its relation to heart failure, and, relevant to


  4   this meeting, cardiac progenitor cells of different


  5   kinds.


  6             DR. SIMONS:  Hi.  I am Michael Simons.  I


  7   am Chief of Cardiology at Dartmouth Medical School.


  8   I work in the area of vascular biology, gene and


  9   cell therapy.


 10             DR. RUSKIN:  Good morning.  I am Jeremy


 11   Ruskin.  I am a cardiologist and


 12   electrophysiologist, and I direct the  Cardiac


 13   Arrhythmia Service at Massachusetts General


 14   Hospital.


 15             DR. NEYLAN:  Good morning.  I am John


 16   Neylan.  I am a nephrologist and an organ


 17   transplanter by training. Currently, I am Vice


 18   President of Clinical Research and Development at


 19   Wyeth, and I serve as a industry representative to


 20   the committee.


 21             DR. KURTZBERG:  Hi.  I am Joanne


 22   Kurtzberg.  I am a pediatric oncologist.  I direct


 23   the Pediatric Bone Marrow and Stem Cell Transplant


 24   Program at Duke University and the Carolinas Cord


 25   Blood Bank at Duke.




  1             DR. ALLAN:  Hi.  I am Jon Allan.  I am a


  2   virologist at the Southwest Foundation for


  3   Biomedical Research.  My area is nonhuman primate


  4   models for AIDS pathogenesis.


  5             DR. CANNON:  Good morning.  I am Richard


  6   Cannon.  I am at the National Heart, Lung, and


  7   Blood Institute.  I am Clinical Director of NHLBI,


  8   and I am representing NHLBI at this meeting.


  9             DR. ROSE:  Good morning.  I am Stephen


 10   Rose.  I am Deputy Director for the Recombinant DNA


 11   Program in the Office of Biotechnology Activities


 12   in the NIH.


 13             DR. JENSEN:  Good morning.  My name is


 14   Nick Jensen.  I am a reviewer in the Center for


 15   Devices and Radiological Health.  I am a


 16   veterinarian and an engineer.


 17             DR. McFARLAND:  Good morning.  I am


 18   Richard McFarland.  I am a reviewer in the


 19   Pharm/Tox Branch in the Center for Biologics in the


 20   Office of Cellular, Tissue and Gene Therapies.


 21             DR. RIEVES:  Good morning.  My name is


 22   Dwaine Rieves.  I am a medical officer in FDA's


 23   Center for Biologics Evaluation and Research.


 24             DR. GOODMAN:  Good morning.  I am Jesse


 25   Goodman.  I am the Center Director of the Center




  1   for Biologics.  I would just like to join in


  2   welcoming especially the new members.  My


  3   background is as an infectious disease physician in


  4   academic medicine for many years.


  5             DR. NOGUCHI:  I am Phil Noguchi, Acting


  6   Director of the Office of Cellular, Tissue and Gene


  7   Therapies in CBER.


  8             DR. RAO:  Thank you, everyone.


  9             We are very fortunate in having some


 10   really leaders in the field come and present some


 11   of the data which will be the basis of where we can


 12   address some of the questions that have been raised


 13   by the FDA.


 14             I am going to ask them to just briefly


 15   introduce themselves, as well.


 16             DR. EPSTEIN:  I am Steve Epstein, a


 17   cardiologist.  I am head of the Cardiovascular


 18   Research Institute at the Washington Hospital


 19   Center.  We are involved in vascular biology, gene,


 20   and cell therapy.


 21             DR. MENASCHE:  I am Philippe Menasch.  I


 22   am cardiac surgeon at the Hospital European George


 23   Pompidou in Paris, France.


 24             DR. PERIN:  Good morning.  I am Emerson


 25   Perin.  I am an interventional cardiologist and




  1   Director of Interventional Cardiology at Texas


  2   Heart Institute in Houston.


  3             DR. TAYLOR:  Hi.  I am Doris Taylor.  I am


  4   a scientist.  I just moved from Duke University to


  5   the University of Minnesota to head the Center for


  6   Cardiovascular Repair.


  7             DR. ITESCU:  Hi.  I am Silviu Itescu.  I


  8   am Director of Transplantation Immunology at


  9   Columbia Presbyterian, New York.


 10             DR. RAO:  I would also like to welcome Dr.


 11   Viner who is from Health Canada.  Health Canada has


 12   been following a lot of what the FDA has been doing


 13   and it is nice to have them there.


 14             I would like to invite Dr. Goodman to make


 15   a statement.


 16                       FDA Opening Remarks


 17           Presentation of Certificate of Appreciation


 18                        to Retiring Member


 19             DR. GOODMAN:  My main purpose is to thank


 20   Joanne Kurtzberg for I guess about four years of


 21   service to the BRMAC.  We really appreciate that


 22   tremendously.  She has also interacted with CBER


 23   before that.


 24             One of the reasons I really wanted to come


 25   by this morning.  Joanne is rotating off this




  1   committee.  I know from interactions both within


  2   this committee and outside, and from all the


  3   leadership and staff within CBER, just what a


  4   tremendous advisor and asset Joanne has been for


  5   FDA and for your various fields here.


  6             Of course, she has mostly contributed very


  7   extensively in her areas of hematopoietic stem


  8   cells, et cetera, but she has also been a very


  9   important thinker and discussant and contributor on


 10   the whole range of other cellular therapies and


 11   even gene therapy.


 12             Please join me in thanking Joanne for her


 13   service over these years.  Also, we like to say,


 14   particularly CBER, that we are a family and that


 15   nobody ever leaves it, and that we, just like a


 16   family, we will keep asking for favors in the


 17   future and probably causing grief in return.


 18             Thanks so much, Joanne.  We have a plaque


 19   for her, of course.


 20             [Applause.]


 21             DR. GOODMAN:  I guess I will just turn it


 22   over to Phil to just give a brief introduction for


 23   the meeting, but just to say that, as I mentioned a


 24   little while back about the islet cell therapies,


 25   we, at FDA, are extremely excited about cellular




  1   therapies and their potential, and I think nowhere


  2   is some of that potential clearer, but also perhaps


  3   more difficult to evaluate and help move forward


  4   than in the area of cardiovascular disease whether


  5   it is for ischemic disease or heart muscle disease


  6   or trauma, et cetera, some of the uses where there


  7   have been some very promising reports.


  8             So, we think this is a very timely


  9   meeting.  It is very important to get input about


 10   how to go forward with efficient development of


 11   those products, how to address some of the clinical


 12   and safety issues, and how to hopefully make this


 13   field positioned to realize its successes in the


 14   most efficient manner and also help FDA get that


 15   right to the extent that we all can based on


 16   incomplete information.


 17             Again, we really look forward to this.  I


 18   apologize, my usual schedule means I will be in and


 19   out,  but I really appreciate it.


 20             Phil.


 21             DR. NOGUCHI:  Thank you, Jesse, and, of


 22   course, Dr. Kurtzberg, our sincere thanks for the


 23   many years of service.  Jesse is absolutely right,


 24   don't be surprised if the next meeting, you get a


 25   funny call early in the morning.




  1             This is one of our, in a way, continuing


  2   series of dealing with things that seem really


  3   wonderful and amazing when they come up, where


  4   there is a lot of hope and there is perhaps a


  5   little bit of hype, but what we have always found


  6   over the years, and here I would like to just


  7   acknowledge Dr. Rose in the Office of Biotechnology


  8   Activities and the Recombinant DNA Committee, what


  9   we have learned from them is that one of the best


 10   ways that we have of really dealing with things


 11   controversial and where there is both hope and


 12   there is some trepidation about whether or not this


 13   is actually going to work or not, is to bring


 14   everyone together, put them in the same room.


 15             Our continuing--and this really goes back


 16   at least 25 years through the RAC and many years


 17   for the BRMAC--is that when you get reasonable


 18   people together who may have differing opinions


 19   about things, but are presented the facts and the


 20   realities, as well as the unknowns, we all


 21   basically pretty much come out with the same


 22   conclusion, and then we can make significant


 23   progress in making these therapies not just


 24   experimental, but a reality.


 25              With that, what I would really like to




  1   do, because we have such a full schedule, is now


  2   turn it over to Dr. Rieves for the introduction.


  3             DR. RAO:  As Dr. Rieves comes up to the


  4   mike, I just want to remind people of a few simple


  5   rules.  Remember that when you want to ask a


  6   question, make sure that you are recognized.  Use


  7   the button.  You will see that the light comes on.


  8   When you are done, just hit the button again to


  9   switch it off, because otherwise, there is sort of


 10   a feedback loop and noise.  Make sure you identify


 11   yourself when you ask questions.


 12              Cellular Therapies for Cardiac Disease


 13                FDA Introduction and Perspectives


 14             DR. RIEVES:  Good morning.  My name is


 15   Dwaine Rieves.  I am a medical officer within FDA's


 16   Center for Biologics Evaluation and Research.  This


 17   morning I am going to present a brief overview of


 18   FDA's perspective on cellular products used in the


 19   treatment of cardiac diseases.


 20             As will be covered in a subsequent


 21   presentation, certain cellular products, when


 22   either perfused into the heart or directly injected


 23   into heart muscle, are thought to be capable of


 24   regenerating heart tissue and/or augmenting heart


 25   function.




  1             Consequently, these products may have


  2   special utility in the treatment of heart failure


  3   and certain other cardiac diseases.  Today and


  4   tomorrow, we will discuss issues in the early


  5   clinical development of these products.


  6             [Slide.]


  7             This talk is divided into three major


  8   sections. First, I will cite the purpose in


  9   convening this advisory committee.  Secondly, I


 10   will provide a regulatory background on FDA's


 11   understanding and activities within the realm of


 12   clinical development of these products.  Finally, I


 13   will introduce the major questions we have proposed


 14   for discussion.


 15             [Slide.]


 16             Unlike many advisory committees where the


 17   topics center around assessment of data associated


 18   with a specific product or data related to a


 19   specific regulatory concern, our purpose in


 20   convening this committee is not to obtain


 21   definitive regulatory advice, instead, FDA has


 22   convened this committee to listen to, and learn


 23   from, the voiced thoughts and perspectives with the


 24   understanding that this information will enhance


 25   our ability to promote the safe clinical




  1   development of these products.


  2             As you are aware, the clinical development


  3   of cellular products is in its infancy and many


  4   questions surround the very early stages of product


  5   development. Consequently, our purpose today and


  6   tomorrow is to stimulate a solid scientific


  7   discussion of the major facets associated with the


  8   very early clinical development of these products.


  9             As noted here, we will focus upon three


 10   major areas:  manufacturing aspects of the cellular


 11   product, preclinical testing of the products, and


 12   finally, items related to the early clinical


 13   studies.


 14             [Slide.]


 15             What are the cellular products we will be


 16   discussing?  These products may be broadly grouped


 17   into two categories.


 18             Firstly, those manufactured without


 19   ex-vivo culture methodology, that is, the cells are


 20   harvested from humans, processed, and then


 21   delivered to a recipient without maintaining the


 22   cells in culture for a period of time.


 23             In general, these cells consist of bone


 24   marrow mononuclear cells and certain peripheral


 25   blood mononuclear cells, hematopoietic progenitor




  1   cells that are variously referred to as stem cells,


  2   cells thought to be capable of assuming phenotypic


  3   characteristics of non-hematopoietic cells.


  4             The second category consists of cells


  5   that, following harvesting, are maintained in ex


  6   vivo culture for a period of time before final


  7   processing and administration.


  8             In general, these cells consist of those


  9   derived from skeletal muscle tissue, cells


 10   frequently referred to as myoblasts, and certain


 11   bone marrow stromal cells, cells also referred to


 12   as mesenchymal cells.  Whether these cultured cells


 13   should be regarded as forms of stem cells is more


 14   questionable than that for the hematopoietic


 15   progenitor cells.


 16             Lastly, as the slide notes, most of the


 17   cellular products we will be discussing today and


 18   tomorrow are of autologous origin.


 19             [Slide.]


 20             The many questions surrounding the


 21   scientific basis for cellular product development


 22   illustrate the very nascent nature of the field.


 23   As we are probably all aware, there is almost no


 24   precedent for the clinical development of products


 25   intended to regenerate and/or augment disease




  1   tissue.


  2             The scientific data surrounding this field


  3   are relatively new, such that the data are limited


  4   in depth and the extent of replication.  Hence we


  5   come to the table of clinical development with many


  6   hypothetical considerations and some, but


  7   relatively limited background supportive data.


  8             [Slide.]


  9             Given these limitations, our discussions


 10   today and tomorrow assume a scientific focus in


 11   which certain insights and perspectives are


 12   presented, and you, the committee members, will be


 13   asked to share your thoughts.  Three points are


 14   cited here.


 15             First, we acknowledge that these thoughts


 16   are all tentative and susceptible to revision based


 17   on accumulating data.


 18             Secondly, we are not requesting any


 19   definitive assessment of data, and we note that the


 20   data presented here today are within the public


 21   arena, and have not undergone FDA vetting.


 22             Finally, I reiterate an earlier comment,


 23   that no specific cellular product discussed here is


 24   under review with respect to regulatory


 25   decisionmaking.




  1             [Slide.]


  2             This slide illustrates the


  3   interconnectedness of clinical research and


  4   regulatory paradigms.  The connecting link between


  5   the two fields is the science.  Clinical research


  6   generates the scientific background for clinical


  7   development of cellular products and the scientific


  8   background forms the major basis for our regulatory


  9   paradigms.


 10             [Slide.]


 11             FDA is charged with many responsibilities,


 12   but as cited here, two are especially relevant to


 13   this discussion. Specifically, FDA's mission is to


 14   promote and protect the public health by optimizing


 15   pre-market product development and ensuring


 16   sufficient post-marketing product monitoring.


 17             The key word in these two statements is


 18   "product." A notation that whereas we frequently


 19   hear the terms transplant, graft, and procedure, we


 20   need to think in terms of a cellular product, a


 21   product that is manufactured, labeled, and


 22   potentially marketed.


 23             [Slide.]


 24             A little over 10 years ago, FDA clarified


 25   the regulatory basis for oversight of clinical




  1   development programs for cellular products.  In


  2   general, this regulatory framework is the same as


  3   that for the drugs and biologic products we


  4   commonly recognize as marketed products.


  5             Hence, the commonly cited biologic


  6   product, drug, and device regulations applied to


  7   the clinical development of these cellular


  8   products, and the clinical studies must be


  9   conducted under the purview of submission of a


 10   investigational new drug application.


 11             The last bullet on this slide reminds us


 12   that clinical development programs may be divided


 13   into early and late stages, with the late stages


 14   focused upon the ascertainment of data definitive


 15   to safety and efficacy, and the early stage, what


 16   we are talking about today and tomorrow, focused


 17   upon the ascertainment of exploratory safety and


 18   bioactivity data.


 19             That is, we hope to examine the nature and


 20   extent of background data necessary to introduce


 21   the cellular products into small, sample size,


 22   Phase I clinical studies.


 23             [Slide.]


 24             As previously noted, the keystone


 25   consideration in early clinical development is




  1   safety.  Specifically, we need to ensure that the


  2   tripod of product development is solid. That tripod


  3   consists of manufacturing control and testing


  4   information, sufficient preclinical testing


  5   information, especially information that may inform


  6   the design of a clinical study, and finally, the


  7   clinical study itself.


  8             The next few slides will cite each of


  9   these three components.


 10             [Slide.]


 11             Cellular products must be manufactured in


 12   some manner, that is, the cells must be harvested


 13   and processed prior to administration to a


 14   recipient.  Manufacturing aspects may be divided


 15   among four major areas, three being shown on this


 16   slide.


 17             The top bullet notes that documents should


 18   describe the cell source and reagents used in the


 19   manufacturing process, such as growth factors,


 20   sera, salt solutions and additives.  We need to be


 21   confident that all the reagents used in the


 22   manufacturing are of clinical or pharmaceutical


 23   grade, or that if they are not pharmaceutical


 24   grade, they are sufficient for human use.


 25             One may envision many potential concerns




  1   with these materials, such as the use of sera that


  2   may contain infections agents, or the use of only


  3   partially purified reagents that contain harmful


  4   excipients.


  5             Secondly, documents should describe the


  6   procedures used in manufacturing, specifically


  7   describing how cells are aseptically harvested,


  8   isolated, and potentially selected.


  9             For example, a distinct population of


 10   cells may be selected based upon the presence of


 11   certain cell surface markers, such as the CD34


 12   antigen with the selection process involving


 13   incubation with an antibody to CD34.


 14             As we know, many investigational


 15   antibodies have been developed to target cell


 16   surface antigens, and we need to be confident that


 17   these selection techniques are performed in a


 18   reproducible and safe manner.


 19             Additionally, documents should describe


 20   the storage and tracking of the cellular products,


 21   this being of special concern because certain


 22   cellular products may be patient-specific products.


 23             For example, measures must be in place to


 24   ensure that for autologous products, the cellular


 25   product is returned to the correct donor.  Of




  1   course, the cellular product needs to be labeled as


  2   one for investigational use only.


  3             The bullet at the bottom of this slide


  4   emphasizes the importance of testing the cellular


  5   product, an especially important concern since


  6   cellular products cannot be sterilized in the same


  7   manner as one might sterilize a drug product or a


  8   device.  Notable aspects of testing include tests


  9   for sterility, endotoxin, viability, enumeration,


 10   or cell counting.


 11             [Slide.]


 12             The fourth component of manufacturing


 13   information is product characterization as


 14   highlighted here.  When one speaks of product


 15   characterization, we are generally talking about


 16   cellular phenotype and/or functional


 17   characterization and the characteristics of the


 18   product's final formulation.


 19             For example, a product containing solely


 20   CD34 positive cells in saline with no preservatives


 21   or media. Product characterization is especially


 22   important from a clinical perspective, because


 23   failure to consistently manufacture a product makes


 24   the clinical data virtually uninterpretable.


 25             As noted here, the major aspects of




  1   product characterization consist of a description


  2   of identity, purity, and potency of the final


  3   cellular product.


  4             [Slide.]


  5             Pre-clinical testing is the second major


  6   component of product development, and the major


  7   aspects of this testing are cited here.  The top


  8   bullet notes that consistent with the science, the


  9   extent and depth of preclinical testing necessary


 10   to support a clinical study is an evolving paradigm


 11   and is a major topic for discussion at this


 12   meeting.  However, we generally take the stance


 13   that this preclinical testing paradigm should be


 14   consistent with that used for other biological


 15   products.


 16             The last bullet notes another important


 17   aspect of preclinical testing, the testing of the


 18   product administration procedure.


 19             This is especially important because many


 20   cellular products involve injection directly into


 21   heart muscle either through the epicardial surface


 22   or the endocardial surface.  These techniques


 23   represent inherent safety concerns that may be best


 24   evaluated in animals prior to their use in humans.


 25             As noted, all available catheters, whether




  1   marketed or not, are regarded as investigational


  2   with respect to administration of cellular


  3   products.


  4             [Slide.]


  5             This slide highlights three aspects of


  6   preclinical testing that will be the focus of the


  7   preclinical questions tomorrow.


  8             Firstly, the choice of the relevant


  9   species is central to designing preclinical studies


 10   with the major choices being between large animals,


 11   such as pigs, versus small animals, such as mice,


 12   as well as the choice between immunocompetent


 13   animals where, for autologous products, the


 14   cellular products would be the animal cells, not


 15   human cells, or immunocompromised animals, where


 16   the actual human cellular product may be tested.


 17             Secondly, designing preclinical studies


 18   raise questions of the choice of model, that is, a


 19   disease model, such as ischemic heart disease


 20   induced in the pig versus a healthy animal.


 21             Lastly, preclinical concerns relate to


 22   testing of the administration procedure itself,


 23   such items as the impact of the catheter materials


 24   upon cells, the potential for occlusion of


 25   catheters by the cellular product, and the safety




  1   concerns associated with manipulation of the


  2   catheters in the heart.


  3             [Slide.]


  4             The third component of the clinical


  5   development program for cellular products is the


  6   clinical study.  There are many aspects of clinical


  7   study design that could be discussed, but at this


  8   meeting, we are focusing upon two, the first shown


  9   here, that is, adverse event detection.


 10             This slide highlights two aspects of


 11   clinical study design that are frequently


 12   engineered to optimize adverse event detection, the


 13   evaluation plan with attention to the duration of


 14   clinical follow-up, the frequency of evaluations,


 15   and the extent or nature of these evaluations.


 16             Secondly, the clinical study safety


 17   monitoring plan may be optimized through the use of


 18   close scrutiny of each study subject based upon the


 19   sequential, not simultaneous, enrollment and


 20   treatment of the subjects, as well as the


 21   prespecifications of the types and numbers of


 22   adverse events that should prompt interruption of


 23   the study, that is, the study stopping rules.


 24             Tomorrow, the committee will be asked to


 25   discuss potential adverse events in these early




  1   clinical studies, both the nature of the events and


  2   ways to optimize the safety of the studies.


  3             [Slide.]


  4             This slide illustrates an additional


  5   clinical study design item that we will bring to


  6   the committee, that is, a discussion of the


  7   analysis of adverse events.


  8             Exploratory clinical studies are, by their


  9   nature, small sample size studies in which it is


 10   often difficult or impossible to distinguish


 11   treatment-related events from adverse events that


 12   might occur in the natural history of the disease,


 13   potential study design mechanisms that might help,


 14   but certainly not resolve this issue are cited in


 15   the bullets, design features that incorporate


 16   randomization of subjects among groups, such that


 17   comparisons may be made, the use of controls,


 18   especially placebo controls, to make comparisons,


 19   the use of masking or blinding to help lessen the


 20   bias associated with concomitant therapies or


 21   clinical care.


 22             Tomorrow, the committee will be asked to


 23   discuss mechanisms that might aid in adverse event


 24   attribution.


 25             [Slide.]




  1             In this presentation, we have covered


  2   three major topics.  Firstly, we have noted that


  3   the focus of this meeting is upon a discussion of


  4   the scientific aspects of early cellular product


  5   development.


  6             Secondly, we have noted the regulatory


  7   precedent for the cellular products.


  8             Finally, we come to the questions.


  9             [Slide.]


 10             This slide highlights the four major areas


 11   of tomorrow's questions.  Specifically, questions


 12   related to manufacturing, we will request a


 13   discussion of the extent of safety testing and


 14   characterization that should be performed prior to


 15   the release of a cellular product for


 16   administration to humans.


 17             The second and third discussion areas are


 18   especially critical and may consume the bulk of our


 19   time, that is, the extent and nature of preclinical


 20   testing necessary to support the introduction of a


 21   cellular product into humans, testing that involves


 22   questions related to the product itself, as well as


 23   the delivery mechanism, the catheter.


 24             Finally, we will pose clinical questions


 25   centered around adverse event detection and




  1   analysis with a discussion of the pros and cons


  2   associated with the use of controls in these


  3   studies.


  4             [Slide.]


  5             Our agenda is summarized on this slide.


  6   As you can see, today, we have a series of invited


  7   presentations by FDA staff and leading


  8   investigators in the field, as well as the


  9   opportunity for public presentations.


 10             Tomorrow, we will have another opportunity


 11   for public presentations followed by a discussion


 12   of the questions.


 13             [Slide.]


 14             In closing, listed here are some documents


 15   that are especially pertinent to our discussions.


 16   All these documents are available at www.fda.gov


 17   under the CBER sites, specifically the guidance


 18   section.


 19             The first document is entitled "Draft


 20   Guidance for CMC Reviewers: Human Somatic Cell


 21   Therapy Investigational New Drug Applications."


 22   This document describes the types of information


 23   FDA reviewers will examine following the submission


 24   of an IND.  Consequently, it provides a very clear


 25   description of the types of manufacturing




  1   information that needs to be submitted with an IND


  2   application.


  3             The second document is from the


  4   International Conference on Harmonization of


  5   Regulatory Practices, and it is entitled "


  6   Preclinical Safety Evaluation of


  7   Biotechnology-derived Pharmaceutics," the S6


  8   document.


  9             This document is cited because it contains


 10   a paradigm that one may apply to cellular products.


 11             Finally, the last bullet cites one of the


 12   most useful guidances to sponsors and


 13   investigators, the ICH Guideline on Good Clinical


 14   Practice.


 15             This guideline provides detailed


 16   information on how to design and conduct a clinical


 17   study, information presented in a simple to read,


 18   yet relatively comprehensive format.


 19             This concludes my presentation and I thank


 20   you for your attention.


 21             [Applause.]


 22             DR. RAO:  Before we continue with the rest


 23   of the presentations, I would like to just welcome


 24   Dr. Harlan and ask him to introduce himself.


 25             DR. HARLAN:  I apologize for being late,




  1   but I am David Harlan, NIDDK.  I study


  2   transplantation of islets and immunotherapies.


  3             DR. RAO:  Our first speaker will be Dr.


  4   Perin, whom you already were introduced to.


  5                        Guest Presentations


  6        Overview Cardiomyopathy and Ischemic Heart Disease


  7             DR. PERIN:  I want to thank you for the


  8   invitation to be here to present to you today,


  9   especially Dr. Grant, who has helped me put this


 10   together in a way.


 11             So, what I want to do here this morning,


 12   the task that has been laid before me is that of in


 13   a way setting the stage or giving you a general


 14   idea of the kinds of patients that we are treating.


 15             Obviously, this is fundamental if we are


 16   thinking about doing clinical trials.  It is very


 17   important to understand the nature of the disease


 18   in which these kind of therapies will frequently be


 19   applied.


 20             What I plan to do is talk about the


 21   following topics.  First, we will start from the


 22   beginning, define what heart failure is, look at


 23   the scope of heart failure, talk a little bit about


 24   the pathophysiology, look at some prognostic


 25   markers, talk about the treatment to some extent 




  1   and that is important in terms of monitoring, and


  2   then really work our way towards end stage heart


  3   failure because that is where I think the focus of


  4   most of the future clinical trials will likely be


  5   initially, and finally, talk about adverse events,


  6   which I think is a major concern, and the


  7   monitoring of there adverse events.


  8             Now, I know many of you are not


  9   cardiologists, so hopefully, I can go from a level


 10   where we are not getting too complicated, but not


 11   too simple.


 12             Starting with the definition of what heart


 13   failure is.  Firstly, heart failure is a clinical


 14   syndrome very simply defined by certain symptoms


 15   and certain signs that come together.  These


 16   symptoms are fatigue, shortness of breath, and


 17   congestion, and these are translated on a physical


 18   exam by being able to hear a third heart sound, the


 19   patient manifesting peripheral edema, and jugular


 20   venous distention.


 21              If we start looking at this problem and


 22   have a broad overview of this, first, I want to


 23   show you a graph from the HOPE trial.  This is a


 24   trial that was conducted in thousands of patients,


 25   as you can see here, over 9,000 patients.  It was a




  1   study primarily of ramipril and vitamin E in


  2   patients with hypertension over a long period of


  3   time, involved a five-year follow-up.


  4             But it is just very interesting, as we


  5   start out looking at heart failure, to look at this


  6   patient population, and here we have over 500 days,


  7   so here is about a year out, and if we look at this


  8   population, who is not primarily designated as


  9   particularly sick or harboring heart failure, that


 10   identified the patients that did have heart failure


 11   and we look at their survival, you will see the


 12   mortality.


 13             It separates from the beginning, and when


 14   we get out to about a year, you have got a 10


 15   percent mortality in the group that has heart


 16   failure compared to less than 4 percent mortality


 17   in the general population.  So, you can see that


 18   the problem that we are dealing with seems to be


 19   very serious.


 20             If we go here and let's just look at the


 21   placebo arms of some very large heart failure


 22   trials, these are trials pretty much aimed at


 23   evaluating different forms of therapy now in heart


 24   failure patients, and looking at different severity


 25   of heart failure patients, for example, in the




  1   V-HeFT trial, inclusion criteria might be an


  2   ejection fraction less than 40 percent.


  3             If we look at PRAISE, which evaluated


  4   amlodipine in more severe heart failure, an


  5   ejection fraction was less than 30 percent,


  6   comparing this with Class III and Class IV


  7   patients, very sick patients.


  8             So, you can see here if we look at just


  9   the placebo arms of all these trials, a very


 10   striking mortality as we go along.  If we look at 1


 11   year here, this will vary from 10 percent down to


 12   around 30 percent.


 13             If we go out to 2 years in the very sick


 14   patients, we see that half of the patients are


 15   dead.  So, heart failure, depending on the


 16   presentation, carries a very ominous prognosis.


 17             It is a very broad problem, 5 million


 18   Americans are living with heart failure now,


 19   550,000 new cases are diagnosed each year.


 20             From 1979 to 2000, heart failure deaths


 21   increased by 148 percent.  Now, what is


 22   interesting, over this period of time, we have


 23   actually gotten a lot better at treating heart


 24   failure, and we do treat it. I will get into this a


 25   little later, and I will show you the modern treat




  1   of heart failure and how much better we are doing,


  2   but at the same time that we are treating heart


  3   failure better, we are also treating the patients


  4   that have coronary disease, which is a very


  5   dominant problem in this country and around the


  6   world,  we are treating those patients better, too,


  7   so what happens is we are getting more patients


  8   with heart disease that normally would have died


  9   earlier, to live longer, and as we are able to


 10   bypass and stent and do all these revascularization


 11   procedures and come up with better treatments, we


 12   are getting people that go further down the road,


 13   that otherwise would have succumbed a long time


 14   ago.


 15             So, despite our improvements in treatment


 16   of coronary disease, we are dealing with an


 17   increasing amount of heart failure deaths.


 18             In individuals diagnosed with heart


 19   failure, cardiac death occurs at 6 to 9 times the


 20   rate in the general population.  If you are more


 21   than 40 years old, you have a 1 in 5 chance of


 22   developing heart failure, and 22 percent of men and


 23   46 percent of women that have heart attacks will be


 24   disabled within 6 years with heart failure.


 25             So, as you can imagine, the high




  1   prevalence and multiple complications have an


  2   implication in terms of health costs.  If we look


  3   at the costs, and these numbers vary, and it


  4   depends on what you are looking at and what year


  5   you are looking at, but this is a very significant


  6   financial burden on the country, over 5 percent of


  7   the total health care costs.


  8             You can see that most of the cost involved


  9   is really involved in inpatient care, and as I will


 10   show you hopefully, that really translates to the


 11   sickest portions of these patients, that as you get


 12   sicker with heart failure, you start coming into


 13   the hospital more, and that is what runs up the


 14   cost of treating these patients.  It is interesting


 15   that transplant is just a little sliver out of the


 16   pie here.


 17             So, let's look at the causes of heart


 18   failure, and I am not going to get into all the


 19   little minor details, but let's look at the major


 20   causes of what brings on heart failure.


 21             Seventy-five percent of people that go on


 22   to develop heart failure had hypertension


 23   previously.  Valvular heart disease is a big


 24   contributor and also heart failure engenders


 25   valvular heart disease, mitral regurgitation




  1   further contributes to the problem.


  2             Coronary artery disease, you are all


  3   familiar with this, the number one problem in this


  4   country, and this is really what we are going to


  5   focus majorly on in terms of causing heart failure


  6   and the specific kind of heart failure that this


  7   engenders.


  8             In cardiomyopathy, there is many different


  9   kinds of things that get a heart to perform poorly,


 10   all the way from an idiopathic cardiomyopathy to


 11   such things as iron overload, et cetera, which are


 12   not as common.


 13             Now, what I want to talk about here is


 14   really systolic heart failure.  There is something


 15   called diastolic heart failure, and that really has


 16   a lot to do with compliance problems of the


 17   ventricle, and in these patients, we are going to


 18   see a normal ejection fraction.


 19             So, this is really a different animal and


 20   it is really not what we are focusing on, so what I


 21   am going to be talking about today is systolic


 22   heart failure, and as I will show you, with the


 23   hallmark being a low left ventricular ejection


 24   fraction.


 25             This is just to give you a practical




  1   example.  This is an angiogram from one of the


  2   patients that we treated with stem cell therapy in


  3   Brazil, who all had an ejection fraction that


  4   averaged about 20 percent.  This patient has an


  5   ejection fraction of 10 percent.


  6             You can see the coronaries are calcified.


  7   This is a catheter in the left ventricle.  This


  8   heart is supposed to be pumping this contrast we


  9   just put into the aorta.  As you can see, it is not


 10   doing that very well at all.  Only 10 percent of


 11   what is in here gets out with each beat.


 12             So, you can tell this is a dilated big


 13   heart that just doesn't contract well.  That is the


 14   picture of severe heart failure right there, and


 15   this is what I want to talk about.


 16             Now, when we talk about heart failure, I


 17   think everybody is aware of the classification.


 18   There is Class I, II, III, IV, which are commonly


 19   used, but it is important to acknowledge this.


 20   Class I involves no limitation of physical


 21   activity, Class II slight limitations, Class III


 22   marked limitations, you can't walk up a flight of


 23   stairs without getting short of breath, and Class


 24   IV, you have symptoms at rest.


 25             If we look at this, if we put Class III




  1   and Class IV together, you see the division is


  2   about a third for each of these pieces of the pie


  3   here.


  4             Now, if somebody comes in with Class IV


  5   heart failure, they are very short of breath at


  6   rest, you can give them some diuretics and they


  7   will feel better.  They are not Class IV anymore,


  8   they are Class III.


  9             So, it is interesting, there has been a


 10   want in development of a little different way of


 11   looking at heart failure, and a staging or


 12   classification put out by joint AHA and ACC shows


 13   four different stages, and really looks at heart


 14   failure more like a disease like cancer.


 15             So, where we can identify patients that


 16   are at high risk of developing it, we can screen


 17   patients, and then we can start treating patients


 18   before they really manifest symptoms of the


 19   disease.


 20             Again, this is a progressive disease and


 21   we are going to end up with people that are


 22   refractory even to all kinds of treatment.  I am


 23   going to go over this a little bit more in detail a


 24   little later.


 25             So, in defining what heart failure is, I




  1   hope I have given you a general idea of the scope


  2   of the problem, just talk a little bit about what


  3   causes it because it is important to understand


  4   that to be able to know how we treat it and how we


  5   monitor these patients.


  6             Usually, we are talking about ischemic


  7   heart disease and we are dealing with a myocardial


  8   insult, which is usually a heart attack, so that


  9   heart attack causes damage to the heart muscle, and


 10   that is going to result in dysfunction of that


 11   heart muscle.


 12             Well, the body is going to try to


 13   compensate this dysfunction and especially in two


 14   major ways.  One is neurohumoral activation, so we


 15   will talk a little bit about this in more detail,


 16   but essentially, these compensatory mechanisms are


 17   going to make the heart change its shape and its


 18   size.  It is something we call remodeling.  It


 19   involves hypertrophy of the myocytes and then it


 20   involves fibrosis and dilatation.


 21             So, these mechanisms that the body helps,


 22   to try to help to reverse what is going on,


 23   actually wind up causing toxicity, hemodynamic


 24   alterations that all lead to remodeling, and


 25   remodeling really is the hallmark.




  1             You saw that big heart.  Well, remodeling


  2   is how you get from a normal small heart, which you


  3   have, to a big boggy heart that doesn't contract.


  4   That is the problem of heart failure.


  5             This was very simply put by Doug Mann in a


  6   nice editorial a few years ago.  Basically, here is


  7   the heart over time, as we have an index event, and


  8   basically, remodeling occurs, the heart gets


  9   bigger, the ejection fraction goes down as time


 10   goes by and symptoms occur as time progresses, as


 11   well.


 12             So, I have told you we have a myocardial


 13   insult. This leads to LV dysfunction and


 14   remodeling, and this really instigates a


 15   neurohumoral response.  In return, this is going to


 16   have an impact on remodeling again.


 17             So, what are these neurohumoral things


 18   that happen?  Well, first of all, most importantly,


 19   is the renin- angiotensin-aldosterone system, and


 20   there are several points in which the body


 21   upregulates the system and ultimately, it acts on


 22   the AT-1 receptor, which will cause


 23   vasoconstriction, proteinuria, again LV remodeling.


 24             As you can identify, here are several


 25   sites in which medications, the mainstay of some of




  1   the therapy for heart failure works, namely ACE


  2   inhibitors that work at this point, ARBs that work


  3   at this point, beta blockers have a role in


  4   inhibiting renin, as well.  So, some of the


  5   mainstay of therapy is actually directed at one of


  6   these mechanisms of compensation.


  7             On the other side, we have sympathetic


  8   activation. We have increased sympathetic activity


  9   that again leads to myocardial toxicity and


 10   arrhythmias, and then on the other side, with the


 11   sympathetic outflow, we get vasoconstriction. This


 12   impacts negatively on the kidney, sodium retention,


 13   more vasoconstriction, and progression of the


 14   disease.


 15             Just to get a slightly little bit more


 16   complicated, just to mention that it is really not


 17   all that simple, there are other things involved,


 18   and we have cytokines, TNF-alpha, IL-6,


 19   inflammation that actually progresses with the


 20   progression of heart failure.


 21             Endothelin is a potent vasoconstrictor.


 22   All these things lead to apoptosis and unfavorable


 23   effects upon the myocyte, but then lead to LV


 24   remodeling, which I have told you is one of the


 25   mainstays of reasons for heart failure.




  1              Now, natruretic peptides are important,


  2   as well. It's another compensatory mechanism that


  3   the body has.  I am sure you are familiar with


  4   these BNP, it's a B-type natruretic protein that


  5   actually comes from the ventricle, the A types


  6   comes from the atrium.  We will just focus on the B


  7   type.


  8             What this does, basically, in response to


  9   elevated pressure inside the heart, we secrete BNP.


 10   This suppresses the renin-angiotensin-aldosterone


 11   system and suppresses endothelin.  It helps with


 12   peripheral vascular resistances, decreases


 13   vasodilatation, and it increases natruresis.


 14             So, if we go on to understand now that


 15   there is an interplay between LV dysfunction and


 16   remodeling, and that basically, this will lead to


 17   low ejection fraction, and that is what we see in


 18   the patients.


 19             On the other hand, as a result of this, we


 20   will start getting a constellation of symptoms, and


 21   it is the combination of having a low ejection


 22   fraction and symptoms that defines heart failure.


 23             Let's look a little bit at the prognostic


 24   markers. I just talked a little bit about BNP.


 25   Well, it is very interesting.  If we divide BNP in




  1   quartiles here, depending on the amount of BNP that


  2   you have circulating, your survival will go down.


  3   It is a prognostic marker, as well as a treatment.


  4   Norepinephrine, the same way.  So, these are


  5   markers of prognosis.


  6             It is very interesting.  These are levels


  7   of BNP, and if you can decrease them, decrease to a


  8   less degree, or here, we have an increase.  So,


  9   depending on which direction your BNP goes, your


 10   survival varies as well, and that is an important


 11   concept.


 12             Let's look at another different kind of


 13   marker. Exercise capacity, peak oxygen consumption.


 14   In the transplant world, this is very important.


 15   Here you see the number 14, so a peak oxygen


 16   consumption greater than 14 or less than 14 has


 17   very different prognostic indicators and in many


 18   centers, this serves as a marker threshold for one


 19   of the criteria for entering the patient into a


 20   transplant program.


 21             You can see here a difference in mortality


 22   from 53 percent mortality over two years in


 23   patients that have an NVO2 of less than 14, to that


 24   of 11 with greater than 14, so this is another


 25   important number in patients with heart failure.




  1             Then, if we look overall and look at


  2   symptoms and hospitalizations, here is a New York


  3   Heart Class I to IV, and this is fairly intuitive,


  4   but as we get more symptomatic, we have an impact


  5   on survival, and as we are getting more


  6   symptomatic, we have an increase in


  7   rehospitalization.


  8             What about ejection fraction?  I just


  9   talked about ejection fraction, and you can see


 10   here, similarly to NVO2, ejection fraction can


 11   divide prognostically how patients will do.  Here


 12   we see more than 20 percent, less than 20 percent.


 13   Here you see a two-year survival, 54 percent, so


 14   half the people dying that have an ejection


 15   fraction less than 20 percent.  At one year, that


 16   is a little over 20 percent.


 17             The same thing, this is a large randomized


 18   clinical trial, ejection fraction less than 40


 19   percent.  Over time, people die more frequently.


 20             Now, let's add a little arrhythmia to


 21   this.  Looking at different levels, the first two


 22   are greater than 30 percent ejection fraction, here


 23   less than 30 percent, so that stratifies that out,


 24   but then if we just add the amount of extra


 25   ventricular beats to this, and if we have less than




  1   10 per hour, more than 10 per hour, and then with a


  2   poorly contractile ventricle, your survival goes


  3   down as we add extra ventricular beats.


  4             One attempt that has been made to sort of


  5   graph this problem, because now I have shown you


  6   many different prognostic markers and different


  7   things we can use to classify these patients to


  8   decide what to do and how to follow them.


  9             One of them is a heart failure survival


 10   score.  There is an invasive model, there is a


 11   non-invasive model.  So, things like cause of heart


 12   failure, resting heart rate, EF, mean blood


 13   pressure, if there is a conduction delay


 14   electrically in the heart, oxygen consumption, and


 15   serum sodium can enter into a risk classification.


 16             Here, you just basically have a graph that


 17   shows according to low, medium, and high, your


 18   survival will vary according to the risk.


 19             In our little schema here, that leads


 20   symptoms and low ejection fraction to heart


 21   failure, what are really the things, though, that


 22   are driving mortality?  They are going to be pump


 23   failure, on the one hand, and arrhythmia, on the


 24   other, because sudden death, as I talked to you


 25   about before, is a very prominent problem in people




  1   that have heart failure.


  2             So, it is the combination of these three


  3   things that will pretty much drive patients to a


  4   lethal exit.


  5             Let's talk a little bit about treatment


  6   now.  What are the goals of treatment of heart


  7   failure?  You want to delay the progression or


  8   reverse remodeling, which you can do in some


  9   patients, and delay the progression and reverse


 10   myocardial dysfunction.


 11             You want to reduce mortality, relieve the


 12   symptoms, improve functional capacity, and reduce


 13   disability, also decrease the intensity of medical


 14   care and hopefully reduce economic cost.


 15             I have shown you we go from initial


 16   injury, initial infarct, we suffer remodeling, we


 17   get a remodeled heart that now has a low ejection


 18   fraction, and over this course of time, we have a


 19   worsening of symptoms, so how are we going to


 20   impact this in terms of treatment?


 21             Well, the two mainstays are neurohumoral


 22   blockade, we have kind of gone over some of the


 23   things that we can do, and we will look at those,


 24   and the other is revascularization.  So, many times


 25   with the use of medication or with the use of




  1   revascularization, we can reverse some of this


  2   remodeling in some patients, and in some patients


  3   we don't.


  4             One thing that is very important in terms


  5   of being able to recover patients that have


  6   remodeled hearts, and that are in this road of


  7   heart failure, is identification of viable


  8   myocardium.


  9             Myocardial viability has clearly been


 10   shown to influence the prognosis of people that are


 11   undergoing revascularization procedures, so if you


 12   have a viable myocardium, you are going to do


 13   better.  You have a chance of improving more than


 14   someone who doesn't.


 15             Just to shift gears for just a second


 16   here, these are electromechanical maps.  These are


 17   representations of the left ventricle.  This is


 18   from a patient in our Brazil stem cell study.


 19             This is an electrical map, this is a


 20   mechanical map.  Let's just look at the electrical


 21   map because I just talked to you about viability.


 22   Very simply, if your cells are alive, they have an


 23   electrical signal that is high.  If you have a big


 24   scar with no cells, you have no electricity, you


 25   have a low electrical signal.




  1             We put it on a little color scale.  Red is


  2   dead or red is very little voltage.  Purple is


  3   high.  Here, you see on this electromechanical map,


  4   an area of myocardial viability.  Again, just as it


  5   is important to understand viability when you are


  6   vascularizing patients that have heart failure,


  7   that have coronary disease, it is also going to be


  8   important, in my view, to understand myocardial


  9   viability when we are applying some of these


 10   therapies, and I think there will be differences in


 11   bone marrow therapies and myoblast therapy, but


 12   that is something to keep in mind.


 13             I just wanted to show you an example of


 14   the very common things that we deal with, so this


 15   is not some esoteric difficult patient to find.  We


 16   come across people like this all the time in the


 17   hospital every day.


 18             This is a patient who was 41 years old, he


 19   had bypass, he stopped up all his vein grafts and


 20   his memory artery, and he had ejection fraction of


 21   20 percent, very similar to the one that I showed


 22   you, and Class IV congestive heart failure.


 23             This gentleman was really delightful.  He


 24   was actually a pilot for a major airline, and


 25   because of his bypass, he had to be put off the




  1   flying, and he was actually in charge of all the


  2   simulators, and he was the guy that graded all the


  3   pilots when they had to come in and do the


  4   simulation testing.


  5             Basically, here, we have a 41-year-old


  6   guy, very active man who has gone bypass, he has


  7   lost his graft, he obviously has very aggressive


  8   disease, and why I hear the talk about why some


  9   people have more aggressive coronary disease than


 10   others.


 11             You see this is his right coronary, it is


 12   completely blocked up, X's mean that you can't see


 13   anything on angiography, so this kind of fills from


 14   the other side by collaterals, see these little


 15   twigs down here.


 16             Then, the circumflex is completely


 17   occluded.  This is a floating marginal branch.


 18   This is supposed to be connected, but this is


 19   totally occluded, as well.  The only artery he has


 20   got left is the one down the front of his heart,


 21   but this is very much infarcted, and has a very


 22   significant blockage here, as well as the takeoff


 23   of this.


 24             So, this patient, there is really nothing


 25   to do, and we are faced with this a lot every day. 




  1   This patient, as I have shown you these curves of


  2   mortality, this patient at our hospital wound up


  3   going for an LVAD type procedure and died, and that


  4   is what we see again and again, so this is a very


  5   serious problem.


  6             So, looking of an overview of treatment of


  7   heart failure, let's see, we have medical-based


  8   therapy, on one hand, we have device-based therapy,


  9   on the other.


 10             On the medical side, we need neurohumoral


 11   blockade, we can have a hemodynamic approach and


 12   also antiarrhythmic approach, so we are going to


 13   use these drugs, ACE inhibitors, aldosterones,


 14   diuretics, beta blockers, and then antiarrhythmics,


 15   such as amiodarone, and then we are going to use


 16   more potent i.v. inotropes that improve


 17   hemodynamics, and asaratide [ph], which is


 18   basically similar to BNP, it is like giving the


 19   patient BNP.


 20             On the other hand, we are going to have a


 21   device-based approach using resynchronization


 22   therapy.  It really hasn't shown a benefit in


 23   survival, but in combined endpoints.  We are going


 24   to put defibrillators into people, and I will show


 25   you how that has improved survival.




  1             Then, we will have ventricular assist


  2   devices, and when all this fails, we have an option


  3   of heart transplant, that is very little available


  4   actually, and as you saw, it is a very little


  5   sliver of what we are able to do.


  6             But as you cumulatively add these


  7   therapies, you are able to impact on survival and


  8   make patients live longer.  Here, you see sort of


  9   adding digoxin and diuretic, adding an ACE


 10   inhibitor, and then adding a beta blocker, we get


 11   progressive improvement.  So, this is pretty well


 12   established in terms of medical therapy.


 13             When we look at defibrillators, here is a


 14   curve. This is from the MADA-2.  This is primary


 15   prevention, defibrillator in patients, previous MI,


 16   LVF less than 30 percent, a very significant


 17   survival difference in the patients that get a


 18   defibrillator, so treating the arrhythmias is also


 19   important.


 20             Back to our schema of the different


 21   classification of stages of heart failure.  You see


 22   that we can gradually, we start with ACE inhibitors


 23   and gradually add different medications, but


 24   everybody kind of goes up these stairs and ends up


 25   here at the top, and that is why we have increasing




  1   mortality from heart failure, because we are


  2   getting people to get to this point where before


  3   they really didn't reach that stage.


  4             Then, we get to a stage of basically


  5   refractory symptoms, so they have been bypassed,


  6   they have had stents, everything has been done for


  7   them, and they have that bad heart, it doesn't pump


  8   well, they have a lot of symptoms, they can't


  9   breathe very well.  Many of them have angina.  I


 10   want to want to give you a little bit of my own


 11   perspective on that.


 12             If we look at current trends, this was


 13   published last week in JACC, very interesting.


 14   Heart failure treatment--this is the survival


 15   curves--heart failure treatment in 1994 to 1997.


 16   Here is a survival curve.  We have improved the


 17   treatment of heart failure.


 18             1999 to 2001, gee, we are doing a lot


 19   better, and this is comparable actually to


 20   transplant from 1993 to 2000, and it really raises


 21   the question if transplant, with the modern


 22   management in medical management of heart failure,


 23   how important is it and what the role of transplant


 24   really is.


 25             Really, there is a gap between a very




  1   invasive transplant or LVAD and the medical


  2   therapy, there really is, and we are here to talk


  3   about stem cell therapy.  There is a gap of


  4   something that could be done that is not quite as


  5   invasive and traumatic as an LVAD or transplant,


  6   and that can improve the patient significantly


  7   since we are doing so well with medical therapy.


  8             I want to talk to you a little bit about


  9   my perspective on end-stage ischemic heart disease.


 10   Basically, as I have told you, we have improved the


 11   medical management, so we have longer survival, we


 12   have improved the vascularization treatments of


 13   coronary disease, we have improved the survival


 14   following a heart attack, and that is why we have


 15   more patients, and now we are using widely


 16   defibrillators, and that is why people are living


 17   longer.


 18             So, this is sort of my understanding of


 19   this end-stage patient.  You progress with coronary


 20   disease until you get to the Stage III and Stage


 21   IV, Class III/Class IV heart failure.


 22             If we look at these patients, sometimes


 23   there will be a little surprise, because some


 24   patients really just have shortness of breath, so


 25   this is a variable.  This may occupy the whole




  1   square or angina may occupy the whole square.


  2             So, some patients predominantly have heart


  3   failure, and these patients that predominantly have


  4   heart failure probably weren't very good at forming


  5   collaterals when they had heart attacks and


  6   developed a lot of scar tissue, and have a very low


  7   ejection fraction.  These are the sickest patients


  8   and the patients that are going to have a very high


  9   mortality.


 10             On the other hand, but also in the Class


 11   III or Class IV, and sometimes we pool these people


 12   together in trials and that is why I am making this


 13   distinction, some people have angina more than they


 14   have heart failure.  These probably have a much


 15   better collateral formation when they had these


 16   events, so their ejection fraction is a little more


 17   preserved.


 18             I have had many patients that have lived


 19   on one artery.  Their whole heart is beating okay.


 20   That one artery feeds everything by collaterals,


 21   but they are in really bad shape.  I mean it's an


 22   illusion that they are doing okay, but they do have


 23   a preserved ejection fraction, and their


 24   manifestation is a lot of chest pain.


 25             So, symptoms can vary from one side to the




  1   other and some patients have a balance here, and I


  2   think we need to keep this in mind when we are


  3   designing these trials.


  4             So, there is a predominant angina, and


  5   this is the kind of patient that got, let's say,


  6   these TMR type procedures.  That is the kind of


  7   population you are dealing with.  The predominant


  8   aspect is disabling angina, preserved EF, 100- to


  9   200,000 new cases per year, and constitute about 5


 10   percent of the patients undergoing angiography at


 11   tertiary referral centers.  This has been studied


 12   in this particular case at the Cleveland Clinic.


 13             One year mortality is still very high.


 14   Then, that other group, predominantly heart failure


 15   symptoms, very low EF, myocardial ischemia, though,


 16   is still present, but with more scar.  No option


 17   really for any kind of revascularization.  One year


 18   mortality, 20 to 50 percent.  I have shown you one


 19   curve where it is up to 80 percent, I mean it can


 20   be really bad.


 21             Here, we have ICD therapy trials.  If we


 22   look at secondary prevention trials, very sick


 23   patients in this study, treated with amiodarone,


 24   you see here one year mortality 44 percent.  I mean


 25   heart failure can be worse than cancer.




  1             Here is the REMATCH trial.  This is an


  2   LVAD.  This is the impact of LVAD, and there is an


  3   impact of survival, but again you are dealing, in


  4   this case, with Class IV patients that are


  5   unresponsive to medical therapy, so these very sick


  6   patients, but again an invasive, costly, not widely


  7   available kind of therapy, but it does have an


  8   impact on failure.


  9             I want to finish now talking a little bit


 10   then, hopefully, I have given you an overview of


 11   the problems with heart failure, and how are we


 12   going to look at adverse events.


 13             Well, what are the things that are going


 14   to drive the adverse events here, are going to be


 15   arrhythmia, ejection fraction, and symptoms, and I


 16   think if we focus here, we can pretty much decide


 17   what we need to look at in these patients over time


 18   as we use new therapy towards these patients.


 19             Let's look at low ejection fraction, how


 20   are we going to monitor that?  Well, we need to


 21   look at cardiac function, cardiac size, and the


 22   perfusion status of the ventricle.  We can do that


 23   very simply, if you take a simplistic approach,


 24   with echocardiography.


 25              I empirically have placed this here based




  1   on my own limited experience here, but I read in


  2   the document that you wanted some more practical


  3   advice, so I will give you my own sort of practical


  4   feel for what I would do.


  5             If we did echocardiogram on these


  6   patients, we could do it monthly for the first


  7   three months and then at six months follow-up.  We


  8   can do SPECT, we know that we don't need it too


  9   early, and that is a very simple way of doing it,


 10   three to six months.  Clinical visits, which will


 11   be very frequent, and I will talk about that, and


 12   BNP can be done for that, as well.


 13             Now, we can get fancy and use alternative


 14   imaging strategies, we can use MRI,


 15   electromechanical mapping, PET, depending on the


 16   institution, and depending on what we are really


 17   looking for and want to find.


 18             Cardiac arrhythmias, it is important to


 19   monitor cardiac rhythm.  Holter monitoring is very


 20   simple, probably should be done after the


 21   procedure, one, three, six months later.  Q-T


 22   interval when the patient comes in for his clinic


 23   visit is a strong predictor of survival, just a


 24   plain-old, good-old 12-lead EKG, and that should


 25   always be looked at.




  1             In the patients I guess that are getting


  2   myoblast therapy, there may be a little bit more


  3   concern about this, and this is really not my area


  4   of expertise, but these patients, many of them


  5   already entering with an AICD, that have sort of a


  6   built-in little computer that is already monitoring


  7   their rhythm as it is.  If they don't, you might


  8   want to consider event monitoring.


  9             For symptoms, well, clinical visits


 10   biweekly for 8 weeks, monthly up to 6 months.  We


 11   are going to look at heart class, we are going to


 12   look at EKG, CBC, CRP, look for inflammation.


 13   Exercise capacity, ramp treadmills, as you know, if


 14   you put a patient that has end-stage heart failure


 15   on a graded treadmill test, every time the


 16   treadmill bumps up and goes a little faster, he


 17   just may not be able to exercise at that point.


 18             So, the advantage of a ramp treadmill


 19   protocol is that you have a gradual continuous


 20   increase, so these people that really can't do very


 21   much at all, they will be able to tolerate the


 22   exercise and probably get further than they could


 23   in any other kind of exercise test.


 24             There is a very simple way of evaluating


 25   an exercise test, a 6-minute walk test.  You just




  1   define a distance, walk the patient walk for 6


  2   minutes, see how fast he can go.  You can do that


  3   at a clinic visit, and it is very simple to do.


  4   So, you can do something like this at one, three,


  5   and six months.


  6             Rehospitalization.  We look at the


  7   rehospitalization rates.  It is important to look


  8   at the use of i.v. medications that are used to


  9   control symptoms, because this is, as you saw, the


 10   biggest part of the pie in terms of costs, and is a


 11   real problem in the end-stage patients.


 12             Quality of life, it is important to assess


 13   quality of life, for example, SF36, Minnesota


 14   Questionnaire.


 15             Just some suggestions.  I want to wrap


 16   this up and saying I hope I have given you a


 17   general idea and scope of this problem.  We deal


 18   with a very, very serious problem, which is heart


 19   failure, specifically, that which is ischemic heart


 20   failure and specifically, end-stage ischemic heart


 21   failure.


 22             I hope I have given you a flavor of this


 23   and set the stage for the discussions.


 24             Thank you very much.


 25             [Applause.]




  1             DR. RAO:  Thank you, Dr. Perin.


  2             There is time for questions, and we can


  3   open it up to the committee.


  4                               Q&A


  5             DR. SCHNEIDER:  Emerson, one of the things


  6   that you did very nicely was lay out the clinical


  7   spectrum for people who may not be familiar with it


  8   in this context.


  9             I wanted to follow up on that point


 10   because work presented at international meetings


 11   recently by the Frankfurt group of Andreas Sire and


 12   Stephanie Dimler suggests that bone marrow derived


 13   cells and circulating progenitor cells from


 14   patients with established heart failure may be


 15   deficient relative to the performance of bone


 16   marrow derived and circulating progenitor cells


 17   from patients with an acute infarct.


 18             So, while it is not quite an apples and


 19   oranges comparison to envision cardiac cell


 20   grafting immediately post infarction or in the


 21   first week post infarction in patients without


 22   severe ventricular dysfunction versus patients,


 23   let's say, two to four months out with mild or no


 24   ventricular dysfunction versus the end-stage heart


 25   failure patients who have been a focus in your talk




  1   this morning, it does seem to me that that clinical


  2   heterogeneity introduces a couple of problems.


  3             I am curious to know how you have worked


  4   those through in your own work.  One of them is


  5   because what we are discussing today and tomorrow,


  6   is autologous cell therapy, I believe that there is


  7   a serious issue of patient-to-patient cell


  8   heterogeneity which has been relatively little


  9   discussed in the field except in these still


 10   unpublished or perhaps one paper has come out in a


 11   secondary journal from Stephanie and Andreas about


 12   the defects.


 13             So, one question is what kinds of


 14   standards should a proposed production center be


 15   required to meet in terms of their ability to


 16   generate cells that perform in accordance with some


 17   standard when there is patient-to-patient variation


 18   of this kind.


 19             Secondly, if you are envisioning putting


 20   cells of different kinds into a so severely an


 21   ischemic background as the 41-year-old former pilot


 22   that you mentioned, doesn't it become important to


 23   clearly distinguish, as the prefatory remarks did,


 24   between mechanisms of action for proposed donor


 25   cells that are aimed at regeneration specifically




  1   versus benefits that are achieved through entire


  2   different mechanisms, such as angiogenesis?


  3             If you put new cells into an ischemic


  4   background, they will surely die, and if the goal


  5   is to achieve angiogenesis in a background where


  6   the native coronary circulation has failed and the


  7   graft has failed, then, it seems to me we need a


  8   clearer resolution of the problem of which cells do


  9   which things well, and really fine-tune much better


 10   than the field has to date, you know, which are the


 11   cells that we want where the spectrum is normal


 12   vasculature, insufficient muscle cells versus the


 13   hypothetical ischemic patient that you described


 14   where revascularization is the major goal.


 15             DR. PERIN:  Well, that's fantastic.


 16             [Laughter.]


 17             DR. PERIN:  I think the basic answer to


 18   your question is I don't know, but, you know, these


 19   are all very good points, starting with the cell


 20   type, we really don't know.


 21             Actually, we have submitted a manuscript


 22   in which we have had the pathology of one or our


 23   patients in our study in Brazil who received


 24   autologous bone marrow, died 11 months later, and I


 25   really can't preempt I guess our publication, but I




  1   think we will be seeing some evidence of myogenesis


  2   and angiogenesis from autologous bone marrow cells,


  3   but we really don't know what we are getting when


  4   we are putting, let's say, autologous bone marrow,


  5   and even in that patient that has, let's say he has


  6   predominantly ischemia, if we want to


  7   revascularize, can we get a predominantly


  8   angiogenic effect, so we really don't know, and we


  9   need to define that.


 10             Mononuclear fraction of the bone marrow is


 11   a very simple approach, the one that we have taken,


 12   and it seems to initially, and we haven't really


 13   done efficacy studies and we are continuing on, but


 14   there is a suggestion that it does, so I think that


 15   we need to take every step that we take should be


 16   put one foot in front of the other, and if  the


 17   mononuclear cell fraction works, I think we can go


 18   from there and keep investigating that.


 19             Now, the average age in our trial was


 20   about 58, and you mentioned the problem--


 21             DR. RAO:  Can I interrupt?  These are


 22   really important questions, but they discuss data


 23   which was not presented in the talk right now.  I


 24   would like to at least focus the questions


 25   initially on the issues that relate to the




  1   presentation right now.


  2             We should really come back to these


  3   questions tomorrow when we discuss exactly these


  4   sorts of issues.


  5             Do you think that that would be okay with


  6   you, Dr. Schneider?


  7             DR. SCHNEIDER:  We will certainly return


  8   to them tomorrow, but I was discussing issues that


  9   were raised in this talk, which was clinical


 10   heterogeneity.


 11             DR. RAO:  Let's then focus, not on the


 12   cells per se, and the choice of cells, because none


 13   of the presentation was related to the production


 14   facility or how the cells would be, or the quality


 15   would be, or how you would choose the mechanism,


 16   but maybe how do you choose patients for a trial or


 17   is there some reasonable way of selecting patients,


 18   that there would be consensus on.


 19             DR. PERIN:  Okay.  So, we will get back to


 20   your first question and really, that is something


 21   that actually, we are working on trying to


 22   understand, is there a thumbprint or is there a


 23   profile in the study by Dimler and their colleagues


 24   looking at the characteristics of cells in certain


 25   patients, and obviously, they may not be the same




  1   in a diabetic, in a severe heart failure, we don't


  2   know, so there is another important we don't know.


  3             Age obviously is a very important thing,


  4   so harvesting cells from a 75-year-old may be very


  5   different than doing that in a 55-year-old, so


  6   these are all questions that need to be answered.


  7             DR. RAO:  Dr. Mul.


  8             DR. MULE:  Given the slides you showed of


  9   the steps toward progression of heart failure, and


 10   given the current interventions along that pathway,


 11   from your perspective, where would you see


 12   cell-based therapy intervention falling into that


 13   step toward complete heart failure?


 14             DR. PERIN:  Right now, at close to the


 15   last few steps, I think ethically, we are propelled


 16   to really study the problem in the patients that


 17   really don't have a proven conventional option for


 18   treatment.  In brief, I would say in the patients


 19   who can't be revascularized, because really medical


 20   therapy, we are going to apply to everyone, so then


 21   we are left with revascularization.


 22             Well, can we revascularize?  Well, we do,


 23   and we do it again and again, and there is a point


 24   where you are out of revascularization options, and


 25   I think that is one  place we are initially now,




  1   then, you could think about applying this kind of


  2   treatment.


  3             DR. HARLAN:  Building upon what Dr. Rieves


  4   mentioned when he gave his introductory comments, I


  5   want to just congratulate you on, it seems like our


  6   task is to weigh the risk-benefit, and you have


  7   outlined very clearly the risk, and I accept that


  8   it is severe, and I also want to congratulate you


  9   on mentioning the JACC paper that was just


 10   published, that showed how dangerous it is to look


 11   at historical controls, because we are making such


 12   rapid progress.


 13             My question is along those lines, not in


 14   this field, I just read in the journal, the


 15   Washington Post, about the great advance that has


 16   been made in super-high statin therapies, and I


 17   wonder if you could comment on that study, that


 18   these super-physiologic statin doses seem to have a


 19   major impact on mortality.


 20             DR. PERIN:  I really don't have an


 21   expertise in a lot of things, and that is not one


 22   of them, so it is really hard for me to comment on


 23   that.  I know that it looks like giving people HDL


 24   in the future may be a very exciting thing, and we


 25   may be able to finally find our liquid plumber kind




  1   of solution for people.


  2             Then, again, statins are just--more and


  3   more if you study statins, you have probably come


  4   to the conclusion it should be in the water pretty


  5   soon, I mean the patient benefit is on every single


  6   aspect of cardiovascular disease.


  7             DR. RAO:  Dr. Kurtzberg.


  8             DR. KURTZBERG:  You mentioned some


  9   practice-based methods to evaluate outcomes and


 10   function in these patients, but I think the


 11   challenge is to determine what the cells are doing,


 12   you know, are they differentiating into other kinds


 13   of cells, are they mediating inflammation, are they


 14   mediating angiogenesis, and I don't see how you can


 15   sort that out by clinical-based study.


 16             Do you know of other technologies that are


 17   on the  horizon that may help with that, that are


 18   non-invasive, or would you consider serial biopsies


 19   in patients like this to answer those questions?


 20             DR. PERIN:  That is a good question.  I


 21   don't know that serial biopsies would be a very


 22   efficient way of evaluating that.  You would have


 23   to have a very precise way of being able to


 24   identify where you put the cells and be able to go


 25   exactly to that same spot.




  1             We do have that technology.  Dr. Lederman


  2   is going to follow me eventually here.  The MRI


  3   field, I think is very promising in that regard in


  4   terms of labeling and following cells.


  5             Now, I really don't know that even


  6   labeling a cell, even if it died, if the label


  7   stays there,  you still see the label, so I think


  8   that we have to even go a step further and be able


  9   to prove the functionality of the cell that is


 10   alive and was implanted.


 11             That can be done on an experimental basis,


 12   so we figure ways out to do that, but this is a


 13   very intriguing problem and a very difficult


 14   problem to evaluate.  I think  you have put your


 15   finger on something that is going to be hard to


 16   know.


 17             DR. DINSMORE:  Jonathan Dinsmore from


 18   GenVec.


 19             I just had a question on your angina heart


 20   failure continuum.  I was confused because most


 21   heart failure patients present without angina, with


 22   symptoms of fatigue, so what percentage of heart


 23   failure patients actually experience angina?


 24             DR. PERIN:  If we are talking about


 25   ischemic heart failure, we are not talking about




  1   other kinds of heart failure, actually, idiopathic


  2   heart failure, you kind of get the same remodeling


  3   and everything except you didn't have that infarct


  4   in the beginning, but you go through the same sort


  5   of pathophysiologic processes.


  6             So, we are talking about ischemic heart


  7   failure. People that have ischemic heart failure


  8   have coronary disease.  Coronary disease is


  9   narrowing of your coronary arteries.


 10             Depending on what your response is, you


 11   will or will not have angina, but angina is one of


 12   the manifestations of coronary disease, and it is


 13   really not a good thing to base a lot on, because


 14   the expression of angina is very variable.


 15             It depends on your pain threshold.  I mean


 16   if you are a diabetic, you may not have as much


 17   pain.  It is a subjective thing subject to


 18   interpretation by the actual patient, so it is


 19   something that is very difficult to evaluate, and


 20   that is why I put the continuum, because it is all


 21   there and you really shouldn't take a patient


 22   population based on angina or based on shortness of


 23   breath.


 24             I think you have got to bring both of


 25   these things together to understand they are sort




  1   of in the spectrum of a similar underlying


  2   pathophysiologic process.


  3              DR. SIMONS:  I would like to come back to


  4   the issues of the differences among the patients


  5   having these kind of therapies.  We have learned


  6   from a number of trials of growth factor therapies


  7   that there is a very large difference in how the


  8   patients respond.


  9             This issue that there are different


 10   subgroups that we are not defining is fairly


 11   critical to the field.  You mentioned one or two


 12   biomarkers, but there seemed to be a general


 13   association of markers as opposed to really


 14   identifying which patients respond in which manner.


 15             What would you suggest as a way of trying


 16   to sort of stratify these patient groups?  Not


 17   suggest ejection fraction, that is probably in a


 18   way sort of crude measure, but in terms of


 19   biological responses.


 20             DR. PERIN:  If we look at the trials of


 21   devices, I think that probably a common way to look


 22   at these patients is exercise capacity.


 23             I think that probably is one of the


 24   unifying parameters that we cannot only use at


 25   entry, but also you are able to follow as a patient




  1   goes along, and if he has a response to therapy, he


  2   will have a positive response in terms of what he


  3   is able to do in terms of function.


  4             That has a very practical translation into


  5   quality of life and people feeling better.  I would


  6   say in a broad sense, that exercise capacity, peak


  7   oxygen consumption might be something that I might


  8   consider an important thing to follow in these


  9   patients, and not just ejection fraction, which is


 10   dependent on a lot of things, how much loading the


 11   ventricle has that day, the amount of mitral


 12   regurgitation, et cetera, so there is a lot of


 13   things that will make that extremely variable.


 14             DR. RAO:  As an extension of that, it's a


 15   very general question.  Is there any problem with


 16   many of these studies which are in high-risk


 17   patients enrolling people for the placebo arm of


 18   the trial?  Not in cell therapy, but maybe when you


 19   do devices or you do assists, has this been


 20   historically a problem for the cardiovascular


 21   field?


 22             DR. PERIN:  Well, it has been done as you


 23   can see, so I have showed you a bunch of studies


 24   where it has been done, and it can be done.


 25             Personally, the way I like to see it is I




  1   want to offer patients that get in the placebo arm


  2   some kind of a treatment, so in our future upcoming


  3   study, what I am going to do is I will tell a


  4   patient you are going to get randomized to maybe


  5   not getting treatment, but if you don't get that


  6   treatment at an X period of time, six months, you


  7   will cross over to get the treatment.


  8             I think that is a humane way of doing it,


  9   in which these patients are very ill and desperate


 10   to get something to help, so again, if you can


 11   cross over, sometimes these placebo patients at


 12   some point after you have achieved your assessment,


 13   then that makes it a more palatable or fair way to


 14   do things maybe.


 15             DR. RAO:  Dr. Cunningham.


 16             DR. CUNNINGHAM:  I just wonder, in your


 17   data, if  you see any difference by either


 18   socioeconomic status or by gender, or by any way of


 19   culture, dividing populations, whether it would be


 20   race or ethnicity or any other factor like that?


 21             DR. PERIN:  You mean in our own--


 22             DR. CUNNINGHAM:  Yes, reading the JACC


 23   data, was there anything by gender, for instance,


 24   or by subpopulation?


 25             DR. PERIN:  Females, there are some




  1   differences in the female population in which there


  2   are some differences. There is the catch-up


  3   phenomenon in the end, but socioeconomic


  4   differences, I am not aware that it would have an


  5   impact on that, as well, but maybe gender


  6   differences, yes.


  7             DR. RAO:  One question to sort of follow


  8   on Dr. Simons' question, in at least the way I


  9   understood it, it is really kind of difficult to


 10   stratify patients or to extrapolate from one class


 11   of patients to the other.  Historically, that has


 12   always been a problem.


 13             Again, it's a general feeling when one


 14   conducts studies in the cardiovascular field, is


 15   there some consensus  that everybody says that,


 16   well, if you measure by ejection fraction, and we


 17   take patients, which is what it seemed like a lot


 18   of studies have done, that that is a reasonable


 19   criteria that you can extrapolate from one


 20   classification of that kind to the next, or one


 21   cannot?  Just as a general statement.


 22             DR. PERIN:   It has been done, and it is a


 23   general way of separating--there is definitely a


 24   correlation with your ejection fraction and your


 25   survival, so it is probably not the most refined




  1   way of dividing patients, and it depends where you


  2   make the cutoff, so if you make a fairly high


  3   cutoff, let's say, patients that had ejection


  4   fraction less than 40 percent, then, you are


  5   including most of the population of patients that


  6   have heart failure, so it's a general way to divide


  7   things.


  8             If you start decreasing that number of


  9   that cutoff, then, you are really selecting out


 10   more I think subpopulations we were talking about,


 11   maybe some different kind of subpopulations of


 12   patients with heart failure.


 13             DR. RAO:  Dr. Borer.


 14             DR. BORER:  Dr. Rao, a few minutes ago you


 15   made a point, and I would like to restate it in


 16   another way, because what Dr. Perin did, as I see


 17   it, is very well present an overview as an outline,


 18   was a scaffold upon which we can conduct subsequent


 19   more specific discussions.


 20             I think that right now we are getting into


 21   a series of questions that are way beyond the data


 22   that exist, and you couldn't expect Dr. Perin to


 23   respond to them in a meaningful way because the


 24   data don't exist.


 25                In specific response to your question,




  1   which was a very fundamental one, I think we are at


  2   a point now with this form of therapy where if we


  3   could define any group in which we saw a response


  4   which seemed credible, which was statistically


  5   valid, we would then have a series of hypotheses


  6   that would have been generated that would allow one


  7   to move further, but I think that is the level we


  8   are at.


  9             The idea of defining a general population


 10   in which to test therapy the way we do with drugs,


 11   we are not there yet, so I think the specific


 12   questions have to come a little later in this


 13   forum.


 14             DR. RAO:  I just wanted to get it clear to


 15   people that that was the case, but your point is


 16   very well taken.


 17             Dr. Neylan.


 18             DR. NEYLAN:  Thank you.


 19             That was a very nice clinical overview,


 20   and I wanted to ask you from your perspective as a


 21   clinician, there are obviously many parameters


 22   whose relief or improvement would be significant in


 23   terms of the lives of individual patients, and many


 24   of these could be utilized as endpoints for proof


 25   of concept.




  1             But ultimately, what do you believe is the


  2   most relevant clinical endpoint for defining


  3   registration criteria for this form of therapy, is


  4   it patient mortality or something else?


  5             DR. PERIN:  I don't know if we are going


  6   to be impacting patient mortality.  That is a very


  7   difficult question.  I would go back and what I had


  8   said earlier, and use an endpoint, I would use


  9   something like the LV02 as an endpoint.


 10             I think that is a little bit more


 11   palpable, and obviously, looking at mortality, this


 12   is such an initial incipient field in which we have


 13   barely treated any patient, so to think about


 14   looking at mortality, which involves a much larger


 15   number of patients, I think that is probably


 16   getting ahead of ourselves a little bit.


 17             We need to first verify if this is


 18   efficacious and if there is some objective


 19   improvement in these patients, and one of those


 20   objective ways of doing that would be something


 21   like exercise capacity, like I mentioned.


 22             DR. RAO:  Dr. Ruskin.


 23             DR. RUSKIN:  Just two quick comments on


 24   Dr. Perin's very nice presentation.


 25             One is that we have learned from drug and




  1   device trials that both ejection fraction and heart


  2   failure classification are critically important


  3   predictors, but that they are not necessarily fully


  4   interactive, that is, they are independent, so


  5   using both, I think in any classification with


  6   regard to these kinds of interventions would be


  7   critical because the outcomes are very, very


  8   different in Class III and IV even with the same


  9   EF.


 10             The other relates to a question that Dr.


 11   Rao raised about recruitment and controls.  I think


 12   that given the excitement in this area, but the


 13   unknown issues that have already been raised, doing


 14   trials that have adequate controls perhaps is more


 15   important here than anywhere else one can imagine


 16   given the severity of the illness that we are


 17   dealing with and the kinds of outcomes that Dr.


 18   Perin has described.


 19             As someone who recruits for device trials,


 20   though, I can tell you that it is not easy, and


 21   randomizing patients to acceptable controls in this


 22   kind of illness is going to be a huge challenge,


 23   but I think it is important for this group to


 24   emphasize that there is no place where this could


 25   be more important, otherwise, we will never get an




  1   answer, and I think that mortality ultimately will


  2   have to be a critical part of any trial that is


  3   done.


  4             DR. RAO:  Go ahead, Dr. Borer.


  5             DR. BORER:  I agree completely with Jeremy


  6   that controls are essential in this kind of


  7   research and really in any clinical research, but I


  8   think again to put this whole area in context, and


  9   in response to Dr. Neylan's point and question, we


 10   are at the point now of looking at physiological


 11   variables and what we would call in drug


 12   development "surrogates," to see whether cardiac


 13   performance, cardiac perfusion, this, that, and the


 14   other thing, is affected in one way or another, so


 15   that one could extrapolate to the point where it


 16   would be legitimate to define hypotheses about


 17   clinical outcome.


 18             We are not there yet, and the clinical


 19   outcome, just to put it in context from the drug


 20   world, is perfectly legitimate in the view of most


 21   people who deal with this area and these agents to


 22   think of a therapy as being approvable if it makes


 23   people feel better, but doesn't make them live


 24   longer.


 25             If it makes people feel better, even if it




  1   makes them live a little bit shorter, as long as


  2   you know how much shorter that is, and if it makes


  3   people live longer while not making them feel too


  4   much worse.


  5             I don't think we are at a point yet again


  6   to define what the outcomes variables should be.  I


  7   think we are at the point of defining physiological


  8   and pathophysiological surrogates, and that is what


  9   is being done in the studies to date, and then we


 10   can decide what the outcomes are, clinically


 11   important for registration.


 12             DR. RAO:  I guess that leads us to the


 13   fact that many of these things should be discussed


 14   tomorrow, just like  you pointed out.


 15             If there are no critical questions


 16   remaining, I will thank Dr. Perin.


 17             [Applause.]


 18             DR. RAO:  We are going to take a short


 19   break.


 20             [Break.]


 21             DR. RAO:  We are really extremely


 22   fortunate in having Dr. Menasch here to present


 23   his findings, and I look forward to a really


 24   interesting talk.


 25                Clinical Experience of Autologous




  1                     Myoblast Transplantation


  2             DR. MENASCHE:  Good morning.  First of


  3   all, I would like really to thank you for the


  4   privilege of this invitation and this unique


  5   opportunity of sharing some data on the clinical


  6   myoblast transplantation.


  7             What I would like to do in this talk is


  8   first to briefly touch on the preclinical data


  9   which have paved the way for these early clinical


 10   trials, and then, as requested by Dr. Grant, to


 11   focus on the various aspects of the clinical


 12   experience which has accumulated so far before


 13   drawing some perspectives which may have clinical


 14   relevance in the near future.


 15             Now, I think just to make things clear,


 16   that the basic assumption is fairly


 17   straightforward, and the objective of this therapy


 18   is really to try to repopulate areas of dead


 19   myocardium with new contractile cells with the hope


 20   that these areas can regain some function, and


 21   given the close relationship between function and


 22   survival, which has been already mentioned, the


 23   ultimate hope is obviously that it can have a


 24   significant impact on clinical outcomes.


 25             The reason why we initially started with




  1   the skeletal myoblasts are actually listed here.


  2   These cells are not really stem cells, they are


  3   better termed precursor cells for muscular fibers


  4   in that they are very committed to their skeletal


  5   muscle phenotype as you will see.


  6              The first advantage of the myoblasts is


  7   that they can be very easily retrieved from the


  8   patient himself, thus overcoming any problem


  9   associated with rejection and immunosuppressive


 10   therapies.


 11             These cells feature a very great expansion


 12   potential which is important given the relationship


 13   which exists between the number of cells which are


 14   injected and the ultimate functional outcome.


 15              As I have just said, they are pretty well


 16   committed to their myogenic lineage, and the risk


 17   of tumor development is virtually negligible.


 18   Finally, they are pretty resistant to ischemia, and


 19   although unfortunately, many of them die shortly


 20   after the injections, fortunately, some of them


 21   will survive and may positively affect function.


 22             So, this is type of animal model which has


 23   been used initially in rodents.  You see here the


 24   heart and the needle injecting the cells.  I just


 25   would like to mention that it took us seven years,




  1   seven years of preclinical work before I did


  2   operate on the first patient June 15, 2000.


  3             During the seven years, we moved from the


  4   rodent models to the large animal models, which I


  5   think is absolutely necessary before arriving to


  6   clinical trials.


  7             Just to summarize the bulk of this data,


  8   we can say, number one, that when you inject


  9   skeletal myoblasts into an infarcted area, they


 10   retain the possibility of differentiating into


 11   typical myotubes.  Here is a typical myotube,


 12   elongated structure, and this is a sheep heart and


 13   this is a human heart.


 14             This is an autopsy specimen.  One patient


 15   of our Phase I trial died 18 months after his


 16   surgery from stroke, and we had permission for the


 17   autopsy.  You will appreciate the striking


 18   similarity of these two slides.  Here you find in


 19   this human heart, a typical myotube embedded in


 20   scar tissue.


 21             At closer magnification, you can


 22   appreciate the typical cross-striations, and I


 23   think two observations are important to be made at


 24   this point.  Number one, these cells really remain


 25   committed to their skeletal muscle phenotype. In




  1   other words, there is virtually no evidence that


  2   they can ever turn to cardiomyocytes.  They will


  3   not become cardiac cells.


  4             Number two, they remain electrically


  5   insulated from the surrounding myocardium, which


  6   obviously raises major mechanistic questions


  7   regarding the underlying mechanisms by which they


  8   can improve function, but the fact is that there is


  9   no real evidence that they develop connections with


 10   the neighboring cardiomyocytes.


 11             Nevertheless, when you subject them to


 12   strong depolarizing currents, they show excitable


 13   properties, and you see here, this is a fluorescent


 14   myotube which has been grafted in a myocardial


 15   scar.  This is an in vivo study and definitely they


 16   can respond to currents by generating action


 17   potentials followed by contractions.


 18             This translates into an improvement in


 19   function, both regional function here in the sheep


 20   model, and global function, the LV ejection


 21   fraction.  This improvement, as you can see, seems


 22   to be sustained over time until one year in our rat


 23   studies, and basically, these kinds of observations


 24   have been made by several other investigators


 25   already past 10 years.




  1             So, there is a fairly good consistency


  2   showing that these myoblasts can, to some extent,


  3   improve function at least in animal models, and


  4   obviously, the gap with the humans is a wide one.


  5             So, if we now move to the clinical


  6   experience, so far there are 44 patients who have


  7   been included in early Phase I trials, and 34


  8   patients currently included in our ongoing


  9   randomized, multi-centered Phase II study .


 10             This list is by far not exhaustive.  I


 11   have not tabulated anecdotal case or me-too cases.


 12   I have just kept those studies which have been


 13   published in peer-reviewed journals.


 14             Basically, the inclusion criteria have


 15   been fairly straightforward across all these


 16   studies.  Patients with low ejection fractions,


 17   usually below 35 percent, patients with a history


 18   of myocardial infarct, and obviously, patients


 19   requiring concomitant coronary bypass surgery since


 20   for ethical reasons, it is difficult to open the


 21   chest just for injecting a product we don't really


 22   know whether it is effective or not.


 23             If we try to summarize the main results,


 24   we can say, number one, that multiple epicardial


 25   injections look to be safe.  I have never seen any




  1   bleeding from the needle holes, and overall, this


  2   experience has been shared by the other surgeons


  3   who have practiced the operation.


  4             Number two, it is possible--and we will


  5   come back on that--that the procedure increases the


  6   risk of arrhythmia postoperatively, at least in the


  7   early post-op period.


  8             Number three, I will be extremely careful


  9   and cautious about that, there are some data


 10   suggesting that maybe function can improve, but it


 11   is clear that until we have the results of the


 12   ongoing randomized, placebo-controlled study, we


 13   cannot make any meaningful conclusion.


 14             This is the list of the studies and of the


 15   patients.  I have just added the last one a few


 16   days ago. Professor Siminiak presented at the


 17   American College of Cardiology another series of 10


 18   patients who got the cells through a percutaneous


 19   catheter using the coronary sinus route.  I will


 20   come back on that catheter in a few minutes, but I


 21   will rather concentrate on the surgical


 22   implantations listed here.


 23             Dr. Smits also injected cells through a


 24   catheter using the interventricular approach


 25   similar to the one alluded to by Dr. Perin.




  1              This goes back to the inclusion criteria


  2   which have previously been mentioned.  I think it


  3   is important to look at all words, because as you


  4   will see, differences in definition may really be


  5   confounders in the interpretation of the results.


  6             It is important to look at akinetic areas


  7   that is really dead myocardium, not simply


  8   ipokinetic or dyskinetic, really akinetic


  9   myocardium, which are not amenable to


 10   revascularization and obviously, it is also


 11   important that the bypass surgery be done in other


 12   areas.


 13             For example, you will see that in one


 14   study, the area which was transplanted with cells


 15   was also revascularized, so when the authors


 16   conclude that cell therapy improves function, it is


 17   clearly meaningless since the same area has got


 18   simultaneous revascularization.


 19             For those of you who are not familiar with


 20   the procedure, I just would like briefly to show


 21   you this three-step operation.  It starts with a


 22   muscular biopsy.  We take it at the thigh.  It is a


 23   very simple procedure under local anesthesia.


 24             We remove a chunk of muscle, which is then


 25   cut into small pieces, put in this sheeping medium




  1   and sent to the cell culture lab where a multiple


  2   tri-cell factory is being designed to allow for


  3   large-scale cell production.


  4             Then, there are regular morphological


  5   controls. Obviously, the key point is to inject the


  6   cells before they reach confluence.  What you would


  7   like to do is that confluence occurs in vivo


  8   following the engraftment, not before, so it is


  9   important to check the morphological state of the


 10   cells on a regular basis.


 11             This is how human myoblasts look like


 12   during the cell culture process, and this is how


 13   the cells look like when they are back in the


 14   operating room.


 15             Then, with the curved needle, we inject


 16   the cells all across the infarcted area including


 17   the borders.  It's a time-consuming, I would say


 18   10, 12, 15 minute procedure, rather tedious and


 19   boring procedure, by the way, where you have to


 20   mentally construct the grids and then go with the


 21   needle from side to side, so we are working on the


 22   multiple shot device, but it is more tricky than we


 23   initially thought.


 24             So, right now we have the requirement for


 25   these multiple injections all across.  This is




  1   another view of the injections.


  2             So, if we start by feasibility, I think it


  3   is quite well established that this technique is


  4   perfectly feasible.  In other words, it does


  5   demonstrate that provided  you have the appropriate


  6   techniques, you can take a small piece of muscle


  7   which contains, say, 3- 4 million skeletal


  8   myoblasts initially and expand it over two to three


  9   weeks until approximately 1 billion cells.


 10             These are the results of our cultures


 11   during the Phase I trial, during which the target


 12   numbers which have been prespecified have


 13   consistently been obtained and even overshoot it.


 14             You will note that you can get up to 90


 15   percent of skeletal myoblasts in that--and this is


 16   an important point--you really end up with a pretty


 17   well defined cell therapy product.  You really know


 18   what you are injecting.


 19             Importantly, what we have seen is that


 20   heart failure does not prevent skeletal myoblasts


 21   to differentiate  into myotubes, and this was a


 22   question because when we did preclinical rounds, I


 23   got pieces of tissue from orthopedic colleagues,


 24   but often these patient were young, and the


 25   question was are the myoblasts from this Class




  1   III/IV heart failure patients going to


  2   differentiate normally, and the answer is yes, so


  3   far we have had no failure.


  4             The only thing is that it may take a


  5   little bit more time for some patients until we get


  6   the target number of cells, but at the end of the


  7   day, it has always been possible to achieve the


  8   prespecified target number of cells in myoblasts.


  9             What about safety now?  These are the


 10   different adverse events we were concerned with by


 11   the time we started the trial, and fortunately, I


 12   must say that none of them has occurred except--and


 13   we are going to discuss that--possibly the


 14   arrhythmias, but it is important to emphasize that,


 15   for example, there was never any particular


 16   bleeding from these multiple puncture sites.


 17             There was no unusual complication in the


 18   postoperative course of these patients, and when


 19   the cells were injected in newt immunocompromised


 20   mice, there was never any evidence for tumor


 21   formation.


 22             Obviously, before we started the study, we


 23   had to go through a lot of regulatory constraints,


 24   indeed, what I did is to discuss with the French


 25   FDA and ask them what was approved or not, and the




  1   game was not so easy because as previously


  2   mentioned, there was no precedent.


  3             So, they told us, well, this is what you


  4   are allowed to do.  This is the kind of culture


  5   medium, ancillary product additives which are


  6   permitted for human use, so we immediately from the


  7   onset designed our cell culture in accordance to


  8   the prespecified instructions, and obviously, it


  9   was timesaving because when we came back with the


 10   process, there was nothing else than to accept it.


 11             Well, what about the V-tachs?  In the


 12   initial series we had 4 patients with sustained


 13   episodes of ventricular tachycardia.


 14             All of them occurred during the early


 15   post-op period, the early three first week,


 16   postoperative weeks, and there was virtually no


 17   recurrence later on because these patients had a


 18   defibrillator put on and only one of them


 19   experienced firing of the defibrillator one year


 20   later, so it really appears to be a relatively


 21   early post-op event.


 22             Now, there are different mechanisms which


 23   could account for these arrhythmias, in particular,


 24   the differences in electrical membrane properties


 25   between the grafted cells and the neighboring




  1   cardiomyocytes.  Obviously, other mechanisms can


  2   also be considered, but we really favor the first


  3   one because we did an EP study in which we looked


  4   at the different membrane properties of the cells.


  5             Here, you see a typical action potential


  6   of a muscular fiber and here of a cardiomyocyte.


  7   Now, if you graft skeletal myoblasts back into a


  8   muscle, these cells retain a typical skeletal


  9   muscle phenotype, and this is also true for


 10   myotubes which grow in culture.


 11             The question is how does it look like when


 12   you graft the skeletal myoblasts into the heart.


 13   Well, definitely it remains very similar to what it


 14   was initially and different from the action


 15   potential of the cardiomyocyte.


 16             If you expressed it graphically, you would


 17   see that the action potential duration is quite


 18   different between the cardiomyocyte and the


 19   myotube, and this heterogeneity might account for


 20   some of these arrhythmias.


 21             Now, having said that, the picture is


 22   probably more complex and the reason, as you know,


 23   and it has been mentioned by Dr. Perin in his talk,


 24   is that heart failure by itself predisposes


 25   patients to arrhythmias.




  1             So, I think that as long as we don't have


  2   the results of the randomized trial in which all


  3   patients have been instrumented with a


  4   defibrillator, it will be difficult to conclusively


  5   establish a causal relationship between grafting of


  6   cells and the occurrence of arrhythmia.


  7             I can also tell you that we currently have


  8   randomized 34 patients in the Phase II trial and


  9   the incidence of arrhythmia has been strikingly


 10   low, much lower than in the initial study we had


 11   done, so things are probably less clear than they


 12   were initially, and once again we have to wait for


 13   the results of the randomized trial before we can


 14   definitely say yes, there is no relationship


 15   between myoblast transplantation and arrhythmia.


 16             Anyway, these patients or most of them


 17   would require at one point a defibrillator, so it


 18   was not a big issue for us to implant those


 19   defibrillators in all the Phase II patients.


 20             Now, what about efficacy?  Now, we have to


 21   be extremely careful in the interpretation of the


 22   results which are presented because of the


 23   multiplicity of the confounding factors.


 24             The culture conditions, for example, the


 25   Spanish group has used a culture medium which




  1   contains the patient's own serum, and the


  2   conclusion is we had no arrhythmia, so if you use


  3   the patient's own serum instead of fetal calf


  4   serum, you prevent arrhythmia.


  5             I think it is really a simplistic


  6   conclusion based on 12 patients, but it can


  7   introduce an additional bias.  There is currently


  8   no evidence that fetal calf serum is really


  9   responsible for the arrhythmias.


 10             Dosing has been extremely different and


 11   variable from one study to the other, as well as


 12   the kinetics of the  grafted area.


 13             Once again, any kinetic area is different


 14   from a dyskinetic area, which features a


 15   paradoxical motion, and, for example, in the U.S.


 16   trial, some patients were included who had


 17   hypokinesia, which we know can improve just because


 18   of the revascularization even if revascularization


 19   is not targeted at this particular area.


 20             The same for bypasses.  In the Spanish


 21   study, for example, the cell grafted areas were


 22   also bypassed, which makes the interpretation of


 23   results impossible.


 24             Type of surgery has also been different.


 25   In the U.S. study, for example, some patients had




  1   additional reconstructions of the left ventricle in


  2   addition to the bypass surgery, which make things


  3   still more complicated.


  4             Finally, the method of outcome assessment,


  5   in some studies, the assessment has been


  6   centralized at one side, in others, each center has


  7   made its own assessment, which obviously makes big


  8   differences.


  9             This is just to illustrate the variability


 10   in the number of cells which have been injected.  I


 11   don't have the figures for the initial surgical


 12   study from Professor Siminiak, but as you can see,


 13   there is a wide variability.


 14             The U.S. study of Dr. Dib was, as you


 15   know, was a dose escalating study accounting for


 16   this variability in the numbers.  Dosing is


 17   probably important.  This is one study among others


 18   showing that there seems to be a tight relationship


 19   between the number of injected cells and the


 20   functional outcomes.


 21             This is the reason why, in our early Phase


 22   I trial, we have targeted a high number of cells,


 23   800 million. In the Phase II, we have two arms with


 24   two different doses of cells, but the number


 25   probably makes a big difference given the high rate




  1   of early cell death.


  2             The characteristics of the grafted


  3   segments, as I previously mentioned, have also been


  4   different from one study to the other, as well as


  5   the method for assessing viability, usually,


  6   dobutamine echocardiography, occasionally MRI or


  7   PET scan.


  8              Same variability in the characteristics


  9   of injections, but you see that you can go up to


 10   almost 60 injections without any concern related to


 11   bleeding, and obviously, the number of injections


 12   depends on the extent of the area of infarction.


 13             It is also important to look at the cell


 14   concentration.  We extensively studied that before


 15   I started doing patients.  You have to find a


 16   tradeoff because if you use a large needle, then,


 17   you can have large holes and some bleeding


 18   problems.


 19             If you use a too small needle, you will


 20   eliminate the bleeding problems, but the cells may


 21   be packed and damaged through their passage, so we


 22   ended with a 27-gauge needle which gave an


 23   acceptable rate of cell viability.


 24             The concentration of cells is important,


 25   and probably still more important when you are




  1   using a long catheter.  We are using a short needle


  2   with directly the serum hooked to the needle, but


  3   if you are using a long catheter, concentration may


  4   make a big difference.


  5             Finally, revascularization is occasionally


  6   being done in the same area as the area where cells


  7   were put in, which completely confuses the results.


  8             This is, for example, the Spanish study,


  9   what you see is that, what they call the untreated


 10   segments, that it is segments which had just


 11   bypassed, the wall motion score went from 1.2 to


 12   1.1 and 1, but really, this is almost normal


 13   motion, so obviously, it makes it easier to


 14   demonstrate that in the other segments which have


 15   bypass surgery and cells, the improvement was


 16   greater.


 17             This is a summary of our data from the


 18   Phase I trial.  We had an improvement in the


 19   functional status and an increase in ejection


 20   fraction.  These results are meaningless because


 21   these patients had associated bypass surgery.


 22             So, we rather looked at the number of


 23   scarred segments, and I remind you these were


 24   akinetic segments without viability on dobutaminic


 25   echocardiography without any possibility for




  1   revascularization.  So, we looked at the changes in


  2   the contractions of these segments which have been


  3   grafted with cells.


  4             So, initially, obviously, there was no


  5   motion since it was one of the inclusion criteria,


  6   and afterwards we had, at two different time


  7   points, approximately 60 percent of segments


  8   regaining some function.


  9             I am not saying that these segments were


 10   normally contracting, they were not.  There was a


 11   slight and modest improvement.  This was a blinded


 12   assessment, in other words, we blinded the dates of


 13   the echo tapes and asked independent


 14   echocardiographers to review them and to grade


 15   them.  There was a modest improvement, not normal


 16   contraction, but it was sufficient to push us to


 17   move forward to the Phase II study.


 18             I just show you a couple of examples.


 19   This is a flat exterior wall, no motion at all, and


 20   this is the same wall with the systolic thickening


 21   following myoblast transplantation.  This is the


 22   MRI study which does not project on the screen.  I


 23   have it on the computer, but not on the screen.


 24             You see here the interior infarct which


 25   has been grafted, and you can appreciate an




  1   improvement in wall motion in the postoperative


  2   period.  This is an exterior infarct.  You see the


  3   thin wall here, which has been grafted, and this is


  4   the post-op pattern with a thickening of the wall.


  5             I add intentionally that these patients


  6   also had bypasses in the left system.  I don't like


  7   the slides where you see pre-transplantation,


  8   post-transplantation, just omitting that in


  9   addition, there was either bypass surgery or


 10   balloon angioplasty.


 11             This is another example of an interior


 12   infarct pre-transplantation and bypass to the


 13   posterior descending coronary artery and the


 14   post-op, with an improvement in the wall motion.


 15             So, now, can it be due to the


 16   revascularization of the PDA?  It is unlikely, but


 17   it cannot be eliminated.


 18             So, basically, this is the design of the


 19   MAGIC, the Phase II trial which has been initiated


 20   now in Europe, in different countries in Europe.


 21   It is targeted to include 300 patients in different


 22   countries, and to emphasize what Dr. Ruskin was


 23   mentioning earlier, it is a placebo-controlled


 24   study.  In other words, patients following


 25   randomization have a muscular biopsy and they have




  1   eventually injection of a placebo solution in


  2   addition to their bypass surgery.


  3             There are three arms, one control and two


  4   treated groups, one having 400 million, the other


  5   having 800 million cells.  The production of cells,


  6   and this is probably important, has been


  7   centralized in two sites, one in Paris and one in


  8   Boston, and it is exactly the same technology which


  9   is used in the two sites.


 10             The primary endpoint is the improvement in


 11   the contractility of the segments which have been


 12   grafted with cells in the core lab and in a blinded


 13   fashion.  In addition to that, we are obviously


 14   looking at major adverse cardiovascular events at


 15   the one-year follow-up time.


 16             I would like to move on now before


 17   finishing to some clinically relevant perspectives


 18   which may have really clinical implications in the


 19   near future.


 20             First of all, so far we have been talking


 21   primarily of ischemia cardiomyopathy, but as


 22   mentioned by Dr. Perin, there are other causes of


 23   heart failure in particular non-ischemic, globally


 24   dilated cardiomyopathy.


 25             So, we have been interested in assessing




  1   myoblast transplantation in this particular


  2   context, and use a particular genetic strain of


  3   hamsters which develop a non-ischemic dilated


  4   cardiomyopathy, and randomize the animals to


  5   receive either autologous skeletal myoblasts,


  6   because phenotypically, these myoblasts are free


  7   from the disease, or culture medium.


  8             To make a long story short, you see that


  9   there is a definite improvement in function which


 10   correlates with a major engraftment of cells in


 11   this non-ischemic myocardium. I think it just


 12   brings another piece of evidence that maybe


 13   something good is occurring.


 14             The second problem is cell death.


 15   Regardless of the cell type, cell death is


 16   extremely high, 80, 90 percent of cells are dying


 17   shortly after the injections for a variety of


 18   causes, in particular, apoptosis, but also


 19   ischemia.  It makes sense since we are injecting


 20   cells in scar areas which receive very little


 21   vascularization.  So, even if myoblasts are fairly


 22   resistant, they die nevertheless.


 23             So, now there are several studies


 24   suggesting that the co-induction of angiogenesis


 25   may be an effective means of improving survival of




  1   the cells, and ultimately, of improving function of


  2   the animals.


  3             This is a study comparing transplantation


  4   of fetal cardiomyocytes, injection of fibroblast


  5   growth factor, or a combination of both.  As you


  6   can see, function is improved when you combine the


  7   two therapies.


  8             Recently, we have duplicated this study


  9   except that we used myoblasts and another growth


 10   factor, and we found exactly similar results.


 11             So, there are different ways of inducing


 12   angiogenesis, and I know Dr. Epstein is going to


 13   discuss that, but the point I wanted to make, this


 14   is, you know, the difference in cell survival


 15   between myoblasts alone and myoblasts plus an


 16   angiogenic growth factor.


 17             The point I would like to make is that


 18   probably in the future, you will have to deal with


 19   proposal of studies trying to combine cell


 20   transplantation with some form of angiogenesis just


 21   to optimize cell survival and potentiate the


 22   benefits of the intervention.


 23             A third point regards cycling.  This is


 24   the muscular biopsy of the patient who died.  I


 25   previously talked about this patient who died from




  1   a stroke.  Initially, in this biopsy, and this is